The process of participating in the political process has changed dramatically over the course of the past year.  In January 2010, the U.S. Supreme Court decided in Citizens United v. Federal Election Commission that, for the purposes of campaign contributions, organizations are citizens and have the right to "unlimited spending in pursuit of political ends."  This is a change of titanic magnitude in our political system.

I have very mixed thinking about the decision.  I generally support free market and libertarian sorts of ideas—including completely unlimited freedom of speech.  But, the power of unlimited corporate contributions in politics does daunt me.  In the wake of this decision however, there is one absolute – we must have transparency in these contributions. Whether by individuals or corporations, all donations to political campaigns, political action committees, the 527 advocacy groups, and the host of non-profit organizations that have grown up doing the bidding of political movements, must be publicly disclosed immediately.  Without transparency, what we have is a political system driven by propaganda (which is commonly differentiated from ‘advertising’ by its lack of identifiable source).  

This issue has new interest in the wake of some recent events.  We had the humorous ‘mock news’ reporter Jon Stewart on the  “The Daily Show” pointing out that the supposedly terrorism-tainted Saudi prince (whose foundation might contribute to the Islamic center much maligned on Fox News), Walid bin Talal, is not only the biggest non-Murdoch shareholder in Fox News’s parent company (he owns 7 percent of News Corporation), but is also the recipient of Murdoch’s mammoth investments in Saudi Arabia.
 
Then, there was a great analysis, “Covert Operations: The Billionaire Brothers Who are Waging A War Against Obama,” by Jane Mayer appearing in The New Yorker.  Its examination of the political funding apparatus of industrialists Charles and David Koch (Charles G. Koch Charitable Foundation, the Claude R. Lambe Charitable Foundation, the David H. Koch Charitable Foundation, KochPAC, and Koch Industries) is fascinating.  These two men, alone, are responsible for a host of ‘political brands’ that we are exposed to every day –  the Cato Institute, George Mason University, the Mercatus Center, Citizens for a Sound Economy, Citizens for the Environment, Americans for Prosperity, Century Strategies, and “Tea Party Talking Points.” 

I support the right of these individuals to say whatever they want, and to fund the means to move their message forward.  However, it is full disclosure and transparency that are a necessity.  Unfortunately, the very modest Disclose Act, which requires corporations to show how they spend money in elections, was recently defeated by Republican filibuster.  Without that, we are left with citizen action—which frequently comes in the form of consumerism—as our only recourse.  Target is one corporation that recently learned exactly how their political investments can impact their relationship with their customers.  It donated $150,000 to Minnesota Forward, a group channeling funds to Minnesota Republican gubernatorial candidate Tom Emmer—known for his opposition to lesbian, gay, bisexual, and transgender rights.  As a result, the company now faces both a consumer boycott and a movement by institutional stakeholders asking for a "comprehensive review" of Target's political donation process.  Still, I think that to rely solely on investigative journalism and institutional investor actions is silly.  We need transparency and disclosure.   After all, why would political contributors want to hide what they really believe?

They say health care is recession-proof. But, that's not exactly the case. The health and human services sector has proven to be both recession-resistant and a recession laggard. And—if U.S. governors are right—the start of the ‘recession’ in the health and human service sector will begin on July 1, 2011. The fiscal year that begins in July will be “the most difficult to date,” according to a survey of 45 states released at the winter meeting of the National Governors Association.

States must find a cumulative $18.8 billion to balance their budgets in remaining months of the current fiscal year, and in fiscal 2011, an estimated $53.6 billion in shortfalls awaits, according to the survey. For governors, Medicaid is one of the top budget issues. Medicaid spending for fiscal year 2009 was $335 billion, an increase of 7.8 percent over the previous year. Enrollment increased 5.4 percent in fiscal year 2009 and will grow 6.6 percent in fiscal 2010. Additionally, 3.3 million more people were enrolled in Medicaid in June 2009 compared to the previous year—the largest one-year increase to date.

If you haven't started your management strategy for this time of economic freefall, now is the time. For starters, employ a three-prong recession management strategy consisting of short-term cash management, business development, and preparing for the post-recession marketplace.

For more, check out:

• Prepare for the Emerging Post-Recession Marketplace: Five Management Best Practices for Organizational Sustainability
• Anticipating Emerging Post-Recession Market Models: Consumer & Payer Demands for Behavioral Health & Social Services

The burden of uncompensated care looms large for most health care organizations—especially with the press pronouncing the "death" of health care reform. For the most part, the term 'health care reform' refers to some package of legislation that has two elements—increasing the number of Americans with some form of health care coverage (particularly catastrophic coverage) and putting in provisions to reduce overall U.S. health care costs. The first is of particular interest to health care provider organizations and the second to small employers like my organization.

Now, you may be like one of my many friends who is celebrating the death of the current set of health care reform proposals. You may say that the free market alone is enough to both reduce costs and provide expanded coverage (one leading to the other)—by having individuals pay for their own health plans and health services. While I'm a fan of many free market elements in health care reform (including consumer vouchers for purchasing plans), I would caution those of you in that camp that the free market alone won't solve the coverage and cost challenges that face us (for many reasons too numerous to list here).

The rumors of the death of any health care reform proposal are going to continue to destabilize any organization in the health service delivery system that is not solely a private pay operation. The rising number of uninsured and inexplicably underinsured Americans will overwhelm the charitable capacity of the delivery system without some paradigm shift. But, I would caution my friends in the health care field to realize that we can't afford universal coverage without cost containment. It's just not a fiscal possibility.

And, as a small employer that provides health coverage to our team, I can state unequivocally that no health care bill will cause increasing stress—both financial and ethical. Over the past two years at OPEN MINDS, we have had two proposed increases in the cost of health care coverage—15% in 2008, and 40% in 2009. So, I wasn't surprised (though the press seemed shocked) at the recent decision by Anthem to raise their premiums by 30-39%.

I hope you'll join me in pushing our representatives of both parties to take action—to move toward a system of universal coverage (even if only for catastrophic coverage) and to come up with rational solutions to reducing health care costs.

Don't miss the great piece "Recent Changes in Medicaid Policy and Their Possible Effects on Mental Health Services” by Jeffrey A. Buck, Ph.D., Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, in the November issue of Psychiatric Services. If you were one of the few remaining people in the field who didn't think that Medicaid funding has come to indelibly change public mental health systems—and will continue to do so—this is a great synthesis of the current and future market effects.

On the system side, Dr. Buck identified the following Medicaid-driven system effects that have already occurred:

• A larger role for state Medicaid authorities in state mental health services and a corresponding decline in the role of mental health authorities;


• Service delivery privatization via Medicaid managed care arrangements which privatize many functions previously provided by public entities


• Increased funding for community-based mental health care


• Increased difficulty in using Medicaid funds for areas not clearly defined within the program;


• Increased accountability of individual service providers via the Medicaid Integrity Program


• Movement away from incentivizing psychiatric institutionalization
  

Dr. Buck also looks ahead to future policy changes. A few are ‘more of the same’—an increase in the role of Medicaid authorities and the growth of community-based services, with continued promotion of deinstitutionalization. In addition, he points to two other developments that are on the horizon. The first is increasing convergence of mental health policy with those that are the norm in primary care. The second is more meaningful consumer participation in treatment plan participation and choice of professionals and provider organizations.

On the board of directors of a health or social service organization? If so, Atlanta’s Grady Memorial Hospital situation is a cautionary tale. A court ruled on September 25th that Grady Memorial—Atlanta's safety net hospital—could close its outpatient dialysis unit. What brought the Grady management team to the place where courts are ruling on its service lines? Consumer desperation, of course.

Grady accepts all patients despite immigration status or ability to pay, and is the ‘last resort’ provider for many uninsured, according to a recent New York Times article. Unfortunately, Grady’s dialysis clinic was projected to lose $2 million this year, and continuing dialysis services was deemed unfeasible. This prompted a lawsuit asking for consumer relief.

The patients’ lawyer, Lindsay R. Jones, called the order Friday by Judge Ural D. Glanville “an angry, punitive decision.” “At least 51 patients had their life support system unplugged today under the authorization of this judge,” Mr. Jones said. In response to the decision, Grady has agreed to pay for up to three months of dialysis at private clinics for the 51 displaced patients. However, the clinic will still close.

The Grady situation is just the first of hundreds of similar situations we are likely to see. The combination of state and local budget deficits—coupled with a likely new range of payer-level health care cost containment measures—will increase pressure on non-profit provider organizations to continue unfunded services.

And don't expect relief from the courts. One quote from Judge Glanville says it all: “As it relates to the receipt of medical treatment, the court is unpersuaded [sic] at this time that plaintiffs have a constitutional right to the sought-after relief."

Word of advice: Understand the cost structure for each service you deliver. Be proactive in seeking additional funding where needed—or in closing those programs you can't afford to continue.

Advocates and provider organization management teams are all tracking state budget problems and what they mean for mental health. A few of my colleagues are breathing a sigh of relief because their state budgets left them 'relatively' unscathed. But, for behavioral health and social services, I think the worst budget cuts are yet to come. In 2010, we will have to deal with the effect of the planned state budgets—and probably some mid-year revisions. But, in many jurisdictions, provider organizations will see county and city budgets for these services unravel. On Saturday, ABC news in El Paso, Texas reported that of the El Paso City Council members, four voted to cut ties with the El Paso Mental Health and Mental Retardation agency. Their rationale is that, by law, those services are the responsibility of the county—not the city. ABC-7 reporter Daniel Marin wrote:

"El Paso City Representative Beto O'Rourke says, by law, MHMR is the responsibility of the county. So he along with special city council committee
members… voted to cut ties with the agency…O'Rourke says MHMR's highly publicized funding issues are the result of the old cliché: too many chefs in the mental health care kitchen…"

"MHMR spokesman Rene Hurtado says while every little bit of funding helps, this is all about more than losing the city's $100,000 yearly contribution. "The mental health care system is very complex," said Hurtado. "The more people we have at the table, the better it is for everyone."

"El Paso County Commissioner Anna Perez says, in her opinion, the city has a direct role in helping the city's mentally ill; adding there's too much at stake for city officials to hide behind a law. "[The law] doesn't mean they don't have a place at the table," she said.

The unfortunate reality? Our current systems for mental health treatment, for addiction treatment, for child welfare, and for other social services are strung together with a hodgepodge of federal, state, county, local, grant, donation, and payer dollars. From my perspective, parity and universal coverage can't come too soon. I'll look forward to a time when Americans with behavioral disorders and disabilities are not begging for safety net funding and charitable donations.