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In Texas, People With Mental Illness Find Work Helping Peers

Recovery coaches and peer mentors — known in Alcoholics Anonymous as “sponsors” — have for decades helped those addicted to alcohol or drugs. Now, peer support for people with serious mental illness is becoming more common. Particularly in places like Texas, where mental health professionals are in short supply, paid peer counselors are filling a gap.

David Woodside, who has lived with bipolar and schizoaffective disorder his whole life, is getting help this way. Not long ago, he wound up in a Dallas County jail for the first time, at age 57. Woodside had gotten upset and kicked his brother.

“Nothing good happens in jail,” he said. “They don’t give you your medication.”

This story is part of a partnership that includes KERA, NPR and Kaiser Health News. It can be republished for free. (details)

After his brothers, including the one he kicked, bailed him out, Woodside enrolled in an anger management class in Dallas at Metrocare, a nonprofit serving people with mental illness in North Texas.

At Metrocare, Woodside started visiting David Yarborough’s office several times a week. Inside, there’s an American flag on the wall, a popcorn machine in the corner and tissues on the wooden desk.

The two Davids have much in common.

Both are fathers and have worked as electricians, and both are taking the same antipsychotic medicine. That’s because Yarborough also copes with mental illness. He’s not a volunteer — he’s a full-time, paid, peer specialist. Woodside said, for him, seeing Yarborough has been better than seeing a psychiatrist.

David Woodside visits David Yarborough’s office several times a week to get helpful coaching on how to manage the symptoms of his bipolar and schizoaffective disorder. “Dave’s been through a lot of the things I’ve been through — and vice versa,” Woodside says. (Lauren Silverman/KERA)

“[Psychiatrists] see you for about six or seven minutes,” Yarborough said. “They don’t know what’s going on with you. And Dave’s been through a lot of the things I’ve been through — and vice versa.”

Metrocare employs five trained peer specialists, including two who are part of the statewide Military Veteran Peer Network. In Texas, more than 900 people have gone through the statewide certification process provided by the nonprofit organization Via Hope. The training requires 43 hours over five days and covers topics such as ethics, effective listening, the role of peer support in recovery and using your personal story as a recovery tool. The certification is valid for two years, and a person needs to earn continuing education credits to renew their certification.

Dennis Bach, executive director of Via Hope, said most of the certified peer specialists are employed by community mental health clinics and state hospitals.

Jim Zahniser, with The Meadows Mental Health Policy Institute, said the idea of peer services has been around for decades but only recently have research studies shown how powerfully effective the approach can be.

“One of the problems with mental health is we’ve learned how to keep people ‘stable’ on their medications and get them out of the hospital. But recovery is about having a life in the community,” Zahniser said. “And peer services are often focused on those things: How do you get your life back?”

Studies show peer support specialists can do as well as traditional case managers — if not better — in keeping patients with severe mental illnesses out of psychiatric hospitals.

And, Zahniser said, when it comes to persuading people who are suspicious of doctors to seek help, peers are often the ones who can connect fastest, and get them to accept treatment.

Peer counselors historically were volunteers. But as the Centers for Medicare & Medicaid Services recognized their value, and more training programs were established and standardized, it became easier for hospitals and clinics to employ these specialists full time.

Texas is one of more than 35 states that finance peer services through Medicaid. There’s a severe shortage of mental health care providers in the state, so certified peer specialists bridge the treatment gap.

Joanne Spetz, a researcher of workforce issues with the Institute for Health Policy Studies at the University of California-San Francisco, says peers play a critical role in mental health teams — alongside doctors and social workers.

“When [programs] first brought in peers,” Spetz said, “[they] had to spend a lot of time with the social workers, explaining to them that we were not going to take their work and hand it off to a cheaper person — that what the peer did was complimentary, but it was different.”

(Martin Barraud/Getty Images)

Peer specialist Yarborough was offered a job precisely because of his success in coping with his own mental illness and overcoming his past use of methamphetamines. When he works with clients, he can talk openly about how, decades ago, he fell into a very dark place.

“I went from the outdoorsman — fishing, yardwork, just really enjoying all that stuff — to … the guy who wants to lie in bed all day and stare out the window,” Yarborough remembers.

He started having suicidal thoughts.

“I gave my wife the key to my gun safe,” Yarborough said, “because I did not feel comfortable having access to my pistols.”

Eventually, Yarborough was diagnosed with bipolar II disorder. His condition has been stable for seven years and he has been drug- and alcohol-free for 10.

When he trained to become a peer specialist, Yarborough said, he learned to work with others while keeping a close watch on his own mental health. Every week, he helps dozens of people manage their symptoms.

His mantra? “It’s not how you fall, it’s how you get back up,” he said. “And I’ve really stuck to that concept.”

There can be a lot of stumbling with a mental illness, Yarborough noted, and having a shoulder to lean on makes the journey much smoother.

The idea of relying on peer providers in this way isn’t unique to the U.S.

“There are many parts of the world where peer specialists are being deployed in the health care system to provide mental health care interventions,” says Dr. Vikram Patel, a psychiatrist and professor of global health and social medicine at Harvard Medical School.

Patel says nearly 450 million people are affected by mental illness worldwide. In developing countries, the vast majority go untreated, he says, because psychiatrists are in such short supply. Patel has looked at the potential of peer support to help meet mental health needs in India and Pakistan.

“We’ve completed trials showing people affected by schizophrenia can be very effective in supporting other people in their own community by befriending them and giving them social support,” he said.

Patel is completing a trial that trains women in a community to help their neighbors recover — mothers suffering from depression.

He hopes Texas and other states in the U.S. continue to experiment with using peer providers, especially to serve people who are finding it difficult to get access to mental health professionals.

“Many groups experience such difficulties — for example, minorities and those who are homeless,” Patel said. “This model is one that should be adopted and integrated into the mental health care system.”

This story is part of a reporting partnership with KERA, NPR and Kaiser Health News.

Senators Grill Top Indian Health Officials About Trump Budget

Kaiser Health News:Madicaid - July 12, 2017

Leaders of the Indian Health Service struggled Wednesday at a Senate hearing to defend the Trump administration’s plans to slash funding to the agency, which is reeling from quality of care problems at several of its hospitals, a doctor shortage and facilities showing their age.

The lack of answers infuriated both Democrats and Republicans on the Appropriations subcommittee.

“I cannot believe what has transpired today. All I want is some damn answers, that’s it,” said Sen. Jon Tester (D-Mont.), as he admonished Rear Adm. Michael Weahkee, the Indian Health Service’s acting director since June.

When Weahkee refused to say how staffing levels would be affected under the Trump administration’s proposed 2018 budget, Tester became visibly shaken and yelled back: “I did not come in here with my hair on fire but I am leaving here with it. … It’s no wonder [the agency is] in crisis.”

Use Our ContentThis KHN story can be republished for free (details).

The administration officials could not answer some basic questions from senators, including how much money the agency has gained from the health law’s Medicaid expansion and whether President Donald Trump’s budget proposal would help the agency to hire more staff.

The Indian Health Service, which oversees care to 2.2 million American Indians and Alaska Natives, has been chronically underfunded, and several of its hospitals have lost accreditation or been put under special watch by Medicare because of conditions that harmed patients. It has a 30 percent vacancy rate for doctors, dentists and physician assistants.

In 2013, Indian Health Service spending for patient health services was $2,849 a person, compared with $7,717 for per capita health care spending nationally, according to a report from the National Congress of American Indians. Despite less funding, Native Americans typically have higher incidences of serious health problems than the general public, including higher rates of diabetes, liver disease and unintentional injuries.

Trump’s budget includes $4.7 billion for the agency. Sen. Lisa Murkowski (R-Alaska), who chairs the Subcommittee on Interior, Environment and Related Agencies, which held the hearing, said that would amount to a 6 percent cut from the current funds. She noted the trim was well below other Department of Health and Human Services agencies, where proposed funding is reduced by an average of 18 percent.

Yet she said she was stunned to hear IHS officials at the hearing say the Trump budget has enough money to improve care.

“You have not answered my question on whether we have provided you sufficient resources,” Murkowski told Weahkee. “I can’t stand down knowing our system is failing so many Native Americans around the country.”

Weahkee, a member of the Zuni tribe, was previously CEO of the IHS’ largest hospital in Phoenix. He said the proposed budget prioritizes funding on patient care, while it cuts funding to modernize and build facilities. He said the agency’s appropriations are augmented by payments from Medicare and Medicaid. Medicaid provided $880 million in funding in 2016 — more than any other third-party funding source, according to a report released Wednesday by Center on Budget and Policy Priorities.

Murkowski said she is worried about the effects on the Indian health care system if Congress were to accept a Republican health plan to replace the Affordable Care Act. The current version being advanced by Senate leaders would end the ACA’s Medicaid expansion and cap future Medicaid funding to states.

Alaska was one of 31 states to expand Medicaid under the Affordable Care Act, and Murkowski has said she has serious qualms about the current plan.

Senate GOP leadership delayed the bill when it failed to get enough support before the July Fourth recess. A new version of the legislation is expected to be released Thursday.

Operating in some of the nation’s poorest places, the Indian Health Service has failed to meet minimum federal standards for medical facilities, turned away gravely ill patients and caused unnecessary deaths, The Wall Street Journal reported last week, citing federal regulators, agency documents and interviews.

Murkowski said she was dismayed by the agency’s recent track record, particularly after she helped steer an extra $29 million in this year’s budget to address quality of care problems at three of its hospitals in the Midwest.

“I believe the agency is sincere in its desire to fix these problems,” she said, “but a year later­ these problems remain and appear to more serious than ever.”

HHS Secretary Price: Alaska Waiver Approval Just the First Step in Era of State Flexibility

HHS Gov News - July 12, 2017

Health and Human Services Secretary Tom Price, M.D., released the following statement on the Centers for Medicare & Medicaid Services and the Department of Treasury’s announcement that they are granting approval to Alaska’s State Innovation Waiver:

“Alaskans have suffered greatly under Obamacare. Premiums on the state’s individual market have tripled since the law was implemented, while just one issuer is still selling plans. HHS has been working with our partners in Alaska to determine how best to provide some relief from this situation.

“The State Innovation Waiver approved today will support Alaska’s reinsurance program, which has already helped put downward pressure on premium increases in the state’s individual market. Alaska predicts that continuing its reinsurance program will lead to lower premiums than the state would see otherwise.

“Washington does not have all the answers when it comes to healthcare. State Innovation Waivers are just one step of many we are taking to inaugurate a new era of state flexibility and innovation in healthcare, and we look forward to more productive work with our state partners.”

Read more about Alaska’s waiver here.

Whichever Way ‘Repeal And Replace’ Blows, Pharma Is Due For Windfall

The pharmaceutical industry could see windfall profits from a little-noticed tweak to the insurance market tucked into the Trump administration’s draft executive order on drug prices, experts say.

The short, technical paragraph calls for the Internal Revenue Service to allow patients with high-deductible health plans to receive care for chronic diseases, including drugs, before meeting their deductibles.

This allowance, known as a “safe harbor,” could be welcome news for patients with chronic conditions like diabetes or asthma stuck with skimpy plans. For example, a diabetes patient could fill her prescription for insulin with just a copay, even if she hadn’t spent enough on medical bills for her insurance coverage to kick in. But in the long term, experts say, extending a safe harbor to chronic care would encourage more employers to adopt these skimpy plans, while shielding the pharmaceutical industry from pressure to lower drug costs.

Use Our ContentThis KHN story can be republished for free (details).

“It’s hard to view this as anything but a substantial win for pharma,” said Kim Monk, a partner and pharmaceutical expert at Capital Alpha Partners, which tracks laws and regulations for financial institutions.

High-deductible health plans have surged in the past five years. The U.S. Centers for Disease Control and Prevention estimates almost 40 percent of patients ages 18-64 must pay $1,300 before receiving insurance coverage, and families must pay at least $2,600. And when faced with high drug prices, more of these patients skip filling prescriptions. Of the millions of insured Americans who struggle to pay their medical bills, 41 percent skip filling a prescription due to cost according to a 2016 Kaiser Family Foundation poll. (Kaiser Health News is an editorially independent program of the foundation.)

These high-deductible health plans are likely to grow if the GOP health plan becomes law, according to the Congressional Budget Office.

But should the White House call on the IRS to offer a safe harbor for chronic disease medications, patients may visit the pharmacy more often despite the high deductibles.

“Yes, this provision could alleviate some of the pharmaceutical industry’s concerns about the increased cost-sharing patients with high-deductible plans could expect under the Republican health care bills,” said Rachel Sachs, an associate professor of law at Washington University in St. Louis who studies the pharmaceutical industry. “As the draft order notes, if high-deductible plan enrollees with chronic conditions can lower out-of-pocket costs for some of their medications, they will be more likely to adhere to their treatment regimens.”

The language of the draft executive order could signal a significant expansion of drug coverage for the growing population with high-deductible plans, according to Stacie Dusetzina, assistant professor of pharmacy and public health at the University of North Carolina-Chapel Hill. Under the Affordable Care Act, preventive drugs were covered before the deductible was met, but the provision was “quite narrowly defined and did not include medications that are used to prevent the progression of disease,” Dusetzina said. “Instead, it was more about preventing the disease altogether. In that way, the executive order could have a big impact on patient access to drugs.”

But unlike coverage under Medicaid or under a plan with a higher actuarial value, the IRS would determine what care and medications are covered. It’s not yet clear whether the safe harbor would extend to essential HIV drugs, insulin or expensive drugs that treat rare diseases.

“You’re asking the IRS to define something the IRS has never had to define before,” said Monk.

The draft executive order explains that the expanded coverage is “for the purpose of helping patients adhere to clinical regimes and thereby reducing the cost of care.” For instance, a patient who can afford an inhaler is less likely to be admitted to the hospital for wheezing. But whether this compliance reduces the cost of care in the long term depends on treatment costs and drug costs, Sachs said.

The safe harbor for chronic care has been championed by the Smarter Health Care Coalition, a partnership linking industry heavyweights including America’s Health Insurance Plans (AHIP), the insurers’ lobbying group; the U.S. Chamber of Commerce; Novo Nordisk; and Pfizer.

The safe harbor will make high-deductible health plans more attractive to employers, according to Tracy Watts, a senior partner at benefits firm Mercer, which could prompt insurers to supply them. “Such a change would go a long way toward encouraging more employers to offer [high-deductible] plans and would boost enrollment,” Watts wrote in a blog post.

The White House has not issued an official executive order on drug prices yet. The draft order, first obtained by The New York Times, has been overshadowed by the political drama over the health bill on the Hill.

Major trade groups have largely avoided shedding political capital on the congressional health care fight — among the most conspicuously absent: PhRMA, the Biotechnology Innovation Organization and the Association for Accessible Medicines, the generic-medicines lobby.

Pharmaceutical companies would see a $2.7 billion annual tax break, but that money would be eclipsed by losses in revenue from Medicaid and Medicare, as well as the drop in demand for health care from the millions of newly uninsured, Moody’s concluded in March.

PhRMA won’t yet say whether it supports the chronic-care safe harbor. “We can’t speak to what the administration will do on this issue and don’t think it would be appropriate to speculate,” said Holly Campbell, deputy vice president of public affairs at PhRMA.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

GOP Health Bill Eases Rules For Some Small-Business Plans

Some small-business owners burdened with high health care costs would get a break from an obscure provision in the Senate health bill. It offers less regulation, more bargaining power and better prices.

But those benefits could come at a cost to others.

The clause — in the proposal advanced by Senate Majority Leader Mitch McConnell (R-Ky.) last month — would exempt insurance sold through “associations” from most Affordable Care Act mandates and state regulations. That means the plans could offer lower-cost coverage that does not include a broad range of medical services or sets premiums based on the health of the businesses’ employees.

In these plans, small businesses can join an association — which may be loosely based on certain types of professional, trade or interest groups — that offers insurance to members.

This KHN story also ran on NPR. It can be republished for free (details).

“Our members are clamoring for more control and more affordable options,” said Kevin Kuhlman, director of government relations for the National Federation of Independent Business, which has long opposed the ACA and supports association plans. The idea also has the backing of the National Restaurant Association.

Critics counter that the provision creates two markets, a lightly regulated one with skimpier and less expensive coverage that would attract businesses with younger or healthier workers and a second market left with mainly older, sicker consumers and rapidly rising premiums.

The Senate plan — along with other GOP proposals that would loosen ACA requirements for some policies — could damage both the small-group and individual markets if it leads to cheaper plans siphoning off the healthiest consumers.

State insurance commissioners warned in a letter Wednesday that the Senate proposal would strip regulators’ authority “to preserve important consumer protections, effectively oversee the plans or ensure a level playing field.” While encouraging the idea of more insurance options, the National Association of Insurance Commissioners said the proposal as written “would lead to significant disruptions in the small group marketplace and higher premiums and fewer coverage choices for many small businesses.”

It would create “an unlevel playing field” that “is likely to lead to cherry-picking, adverse selection and increased costs for sicker individuals,” the American Academy of Actuaries warned in a June 30 letter.

The Senate bill’s language is similar to legislation adopted in March by the House. Previous legislation passed the House in 2003 but never won approval in the Senate.

Association health plans have been around for decades, but some had solvency problems and went bankrupt, leaving consumers on the hook with unpaid medical bills. In several states, regulators investigated whether the plans were advertising that they had comprehensive coverage when, in fact, they provided little or no coverage for such things as chemotherapy or doctor office visits.

The ACA, passed in 2010, still allows the plans but requires them to follow state rules for small-group coverage. That cemented authority in the states to oversee association plans.

The Senate proposal was drafted by longtime proponent Sen. Mike Enzi (R-Wyo.). It would classify association plans as large-group plans, like those offered by major employers to their workers. The large-group plans face far fewer ACA rules and are generally overseen by the federal government.

Large-group plans don’t have to offer the ACA’s 10 “essential health benefits,” and insurers can base their premiums on the health of those covered, although the employer must charge both sick and healthy workers the same amounts. Additionally, most traditional large-employer plans tend to be more generous than the ACA requires. Association plans, by contrast, are not generally as comprehensive as large-employer coverage.

Despite the Senate’s previous rejection of similar legislative language, the idea may have more legs now.   After all, some GOP lawmakers appear to be embracing a similar proposal by Sen. Ted Cruz (R-Texas). It aims to allow insurers to sell individual policies that don’t meet all the requirements of the ACA, so long as they sell at least one type of policy that does.

Support for either Cruz’s plan or the association proposal will run up against opposition from state regulators, actuaries and some small-business owners.

Insurers, they say, would be able to provide minimal benefits, charge small businesses based on the relative health of their workers, or both. That could be a boon for some companies, including some restaurants or other franchise operations that employ mainly younger, healthier workers. Self-employed individuals who are healthy might also be able to join associations and qualify for the cheaper policies. But as those consumers are siphoned off, insurers would raise rates on their other plans, which must follow more stringent consumer protection rules, including those left in the ACA.

“Some small businesses might be able to move into these plans and save money, but that will cause rates to go up for others [with older or sicker workers],” said David Chase, vice president of national outreach for the Small Business Majority, which supports the ACA.

If enough healthy small groups opt for the association health plans, siphoning off those consumers, “the small-group market will go into a death spiral if only employers with sicker and older workers participate,” said Mila Kofman, the former Maine insurance commissioner who now heads the DC Health Benefit Exchange Authority.

Insurance commissioners and actuaries have made similar dire predictions about the effects of splitting the market. Those concerns are overblown, say supporters of association health plans.

Said Kuhlman at NFIB: “The existing marketplace [premium costs] may go up a percentage point or two, but other [small businesses] would have a more affordable plan.”