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When mental health issues become visible, it often happens explosively and tragically. The shootings at Newtown and Virginia Tech, along with countless other deadly crimes, were carried out by mentally unstable individuals. About a year ago, an Iowa veteran dealing with post-traumatic stress disorder was angered by two teens who were horsing around at an Ankeny McDonald’s. He shot and paralyzed one of them.

This is when, like a volcano erupting, mental health explodes across the headlines, only to eventually be replaced by some other disaster or scandal. But, as health care providers well know, the problem not only doesn’t go away, it’s getting worse. In fact, mental health is arguably Iowa’s top public health issue.

Unlike volcanoes, poor mental health and the dangers that can accompany it can be controlled. Where we are failing as both a nation and a state is in providing the right care in the right place at the right time.

Health care providers know this means many of the mentally ill end up in emergency rooms, but perhaps the most tragic evidence of failure are the number of mentally ill inmates in American jails. The National Alliance on Mental Illness estimates that nearly 15 percent of men and 30 percent of women booked into jails have a serious mental health condition. That’s about two million Americans each year.

Here in Iowa, 123,000 people live with serious mental health issues and 80,000 Iowa youths cope with severe emotional disorders. Yet Iowa has fewer psychiatric beds and mental health professionals than nearly every state in the nation.

The idea behind the “deinstitutionalization” of the 1950s and ’60s, and more recently the closing of two Iowa mental health institutes, is that the mentally ill could be helped more humanely while living and being treated in community settings. But the community-based infrastructure was never really put in place or properly supported, so a huge number of those released never got the local help they needed.

Now the price is literally being paid, as Iowans in need of mental health services are churning through emergency rooms and sometimes in jails, places that are costly not only terms of real dollars, but in their inability to properly address an individual’s long-term mental health. Good intentions in the form of deinstitutionalization are not enough, but there are solutions.

This is why during the upcoming legislative session, Iowa hospitals will be advocating for increased behavioral health care access across the continuum to help relieve the systemic bottleneck that has patients languishing in hospital beds or in jails.

Iowa needs a full care continuum in behavioral health that includes sub-acute services, crisis intervention, crisis homes, nursing facility care and community-based services. With that infrastructure in place, more hospital inpatient psychiatric beds will become available for patients who truly need them, while patients needing less intensive care will receive it close to home.

Properly investing in these more efficient and effective resources now will put our state on a path to reduce behavioral health care costs in the long run. Otherwise, reliance on stop-gap measures will continue to extract a high price from both Iowans and Iowa communities.

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(This article was provided by Kaiser Health News.)

Throughout the campaign, President-Elect Donald Trump’s entire health message consisted of promising to repeal the Affordable Care Act.

That remains difficult with Democrats still commanding enough power in the Senate to block the 60 votes needed for a full repeal. Republicans could use fast-track budget authority to make some major changes to the law, although that could take some time. In the short term, however, Trump could use executive power to make some major changes on his own.

Beyond the health law, Trump also could push for some Republican perennials, such as giving states block grants to handle Medicaid, allowing insurers to sell across state lines and establishing a federal high-risk insurance pool for people who are ill and unable to get private insurance.

But those options, too, would likely meet Democratic resistance, and it’s unclear where health will land on what could be a jam-packed White House agenda.

Still, there are several health issues the next Congress and the new administration will be required to address in 2017, if only because some key laws are set to expire.

And those could provide a vehicle for other sorts of health changes that might not be able to clear political or procedural hurdles on their own.

Here are some of the major health issues that are certain to come up in 2017: 

The Affordable Care Act

If the GOP could not repeal the law and Trump were to turn to Congress to address some of the issues associated with it, it’s not clear if the executive and legislative branches could work together to respond to rising insurance premiums, declining insurance company participation or other unintended impacts of the health law. Nonetheless, some aspects of the law are unavoidable next year. For example, Congress in 2015 temporarily suspended or delayed three controversial taxes that were created to help pay for the law.

One of those taxes, a fee levied on health insurers, is suspended for 2017, while a 2.3 percent tax on medical devices was suspended for 2016 and 2017. Both industries lobbied heavily for the changes — arguing that the taxes boosted the prices of their products — and would like to permanently kill the taxes.

Also on hold is the most controversial health law tax of all, the so-called “Cadillac Tax” that levies a 40 percent penalty on very generous health insurance plans. The idea is to prevent consumers who pay little out of pocket because of their coverage from overusing health care services and driving up overall health costs.

The tax was technically put off from 2018 to 2020, but experts say pressure will begin to mount next year for reconsideration because employers will need a long lead time if they are to change benefits to avoid paying it. While economists are virtually unanimous in their support for the tax on high-end health plans, business and labor both strongly oppose it.

Children’s Health Insurance Program

The Children’s Health Insurance Program (CHIP), a federal-state partnership that Hillary Clinton helped set up in negotiations with Congress during her husband’s administration, is up again for renewal in 2017. CHIP covers more than 8 million children from low- and moderate-income households and has made a huge dent in the number of uninsured children. According to the Census Bureau, nearly 95 percent of children had insurance coverage in 2015.

When the federal health law passed in 2010, many policymakers thought CHIP would quietly go away because most of the families whose children are eligible for the program became eligible for tax credits to help them purchase plans for the entire family in the health law’s marketplaces. But it turned out that CHIP in most states remained more popular because it provided better benefits at lower costs than did plans through the ACA.

In 2015, Congress compromised between those arguing to extend CHIP and those who wanted to end it, by renewing it for only two years. That ends October 1, 2017. In practice, if Congress wants to extend CHIP, it needs to act early in 2017 because many states have fiscal years that begin in July and need lead time to plan their budgets.

Prescription Drug And Medical Device User Fees

Also expiring in 2017 is the authority for the Food and Drug Administration to collect “user fees” from makers of prescription drugs and medical devices.

The Prescription Drug User Fee Act, known as PDUFA (pronounced pah-doof-uh), was originally passed in 1990 in an effort to speed the review of new drug applications by enabling the agency to use the extra money to hire more personnel. The user fees were later expanded to speed the review of medical devices (2002), generic copies of brand-name drugs (2012) and generic biologic medicines (2012).

PDUFA gets reviewed and renewed every five years, and its “must-pass” status makes it a magnet for other changes to drug policy. For example, in 2012 the renewal also created a program aimed at addressing critical shortages of some prescription drugs. Earlier renewals also included separate programs that gave pharmaceutical firms incentives to study the effect of drugs in children.

Some policy-watchers think this year the bill could serve as a vehicle for provisions to help bring down drug prices, although it is not clear how well many of the ideas currently being floated would work.

“I think [Congress] will talk a lot about it and do very little,” said Robert Reischauer of the Urban Institute, who called the drug price issue “incredibly complex.”

Medicare’s Independent Payment Advisory Board

One more issue that might come up is a controversial cost-saving provision of the federal health law called the Independent Payment Advisory Board, or IPAB. The board is supposed to make recommendations for reducing Medicare spending if the program’s costs rise significantly faster than overall inflation. Congress can override those recommendations, but only with a two-thirds vote in each of the House and Senate.

So far the trigger hasn’t been reached. That’s lucky because the board has turned out to be so unpopular with both Democratic and Republican lawmakers, who say it will lead to rationing, that no one has even been appointed to serve.

The lack of an actual board, however, does not mean that nothing will happen if the requirement for Medicare savings is triggered. In that case, the responsibility for recommending savings will fall to the secretary of Health and Human Services. Medicare’s trustees predicted in their 2016 report that the targets will be exceeded for the first time in 2017.

That would likely touch off a furious round of legislating that could, in turn, lead to other Medicare changes.

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homeless-oneIn 2014, county and city leaders decided that something needed to be done about central Florida’s alarming homeless population. The issue plagued not just the region’s streets, but also emergency rooms (ERs), health centers and first responders, as homeless people turned to ERs for regular care. Some of the region’s homeless visited the hospital dozens of times in a single year, racking up millions of dollars in services ultimately paid by the hospital systems and taxpayers.

Florida Hospital’s answer: an unprecedented $6 million to support the “housing first” model to end chronic homelessness.

Traditionally, the battle against homelessness has been fought by tracking down the homeless wherever they could be found (if, indeed, they could be found) and offering basic needs (food, water, clothing, first aid) and services such as case management and counseling. In fact, Florida Hospital created a special program, the Homeless Outreach Partnership Effort (H.O.P.E.) Team, to do just that. But the traditional approach put adequate, permanent housing down the list as a “maybe” rather than a “must.”

“Housing first” flips this model, where those who qualify are first given a home and then offered wraparound services aimed at better health, job training and eventually re-entering the workforce to be able to sustain themselves. Those who suffer from severe mental illness and are unable to work also receive priority because they are the highest users of health and public services.

As of last month, 79 formerly homeless Floridians have been placed into permanent housing. And while only a quarter of the $6 million pledged has actually been spent, Florida Hospital and its partners have already seen significant change. Residents now see primary care physicians on a regular basis, are able to manage their chronic conditions and have case managers checking in to make sure they are able to afford their medications. No longer having to worry about where to sleep, they focus on their health, their skills and thriving with dignity.

It’s notable that Florida Hospital, with 2,200 beds and nearly 18,000 employees, is one of the largest in the US, which may cause rural-state hospital leaders to scoff at trying to duplicate the housing first model. Suffice to say, like hospital size, the homeless problem – and the broader adequate housing problem – is relative to location, as would be any response. What’s not in contention is how firmly connected access to housing is to health, overall quality of life and the cost of health care.

Can hospitals solve the homeless problem? No, not even a giant like Florida Hospital can. But that’s not the point. Effective health care is moving steadily from the reactive – trying to fix what homelessness breaks – to proactive – mitigating homelessness as a health issue with preventive care or, ultimately, by supplying permanent, adequate housing.

Of course hospitals can’t fix homelessness, but along with countless other upstream health issues – from childhood trauma to drug abuse to education to nutrition – hospitals are best positioned to form and lead the coalitions necessary to implement lasting solutions. In fact, in the new health care paradigm, there really is no other option.

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Children in Chariton learn basic CPR from Lucas County Health Center staff.

Children in Chariton learn basic CPR from Lucas County Health Center staff.

Results of IHA’s 2015 Community Benefits Survey have been released and show Iowa hospitals provided community benefits valued at more than $1 billion including more than $246 million in charity care. All 118 of Iowa’s community hospitals participated in the statewide survey which is distributed by IHA annually.

Community benefits are activities designed to improve health status and provide greater access to health care and include services and programs such as health screenings, support groups, counseling, immunizations, nutritional services and transportation programs. The total value of these services, as reported in the survey, reaches nearly $172 million.

“Iowa hospitals are uniquely positioned to deliver these programs and services,” said IHA President and CEO Kirk Norris. “No other public or private entity could possibly fill in for hospitals in terms of both assessing and responding to specific community needs.”

Uncompensated care (which is made up of both charity care and bad debt) also plays a role in overall community benefit for services provided by hospitals. Total uncompensated care in 2015 was valued at nearly $520 million. The survey also showed total Medicare and Medicaid losses (at cost) of nearly $370 million.

The community benefits reports display the social and economic importance of Iowa hospitals and health systems. Hospital leaders are encouraged to share hospital-specific data and details of their community benefit services and programs with local media, business leaders and community groups. These efforts help ensure the financial stability of hospitals, making it possible for them to provide the services and programs most needed by their communities.

More information about Iowa hospital community benefits, as well as other hospital quality, safety, economic and utilization data, is available at IHA’s health care consumer website,

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(This column was written by Pam Matthews, a diabetic who lives in Humboldt. Matthews shared her story last month when UnityPoint Health-Fort Dodge hosted United States Secretary of Health and Human Services Sylvia Burwell at Trinity Regional Medical Center. The visit included a round-table discussion focused on the successes of the Pioneer Accountable Care Organization and how it has helped improve care coordination in the Fort Dodge region.)


Pam Matthews and Human Services Secretary Sylvia Burwell

I’m a widow and I don’t have children, but I’m an aunt, a great aunt and a great-great aunt. About two years ago, I tried to fully retire, but I just grew fatter and grouchier, so I started working part-time, taking care of people with intellectual disabilities. I love that work.

In 1997, I wasn’t feeling well. I was thirsty all the time. I knew something was wrong, but I really wasn’t committed to taking care of my health. I shopped around for doctors and each one told me that I had diabetes. But I did not want to hear what they were saying. I was clearly in denial.

I finally had a good moment of clarity with myself in 2011. One day, I had heart failure and an ambulance took me to the hospital. I realized that if I wanted to live and enjoy all my nephews and nieces, I had to take care of my health.

My sister had been seeing Dr. Dustin Smith at the UnityPoint Eagle Grove family health clinic for two years and was happy with him, so I made an appointment.

He told me that I definitely was diabetic and he said a lot more, but he wasn’t just talking at me. When I talked, I realized that he was listening to me. My health care would be a “we decision.”

His manner was very comforting and reassuring. I was obese, but he didn’t harp on my weight. He said he wanted to see me every three months, and he suggested a diabetes education program that would arm me with the knowledge of how to manage my condition. I was paired with a nurse and a care manager out of UnityPoint in Des Moines, who would call and check up on me from time to time. Working with my team, I set realistic goals.

I go to the clinic in Eagle Grove regularly for my blood work and I get the results from the nurse usually within two days. The goal of the clinic was to get patients’ A1C level, which measures blood sugar, down below 7. My number is now 5.8!

It’s so important to keep an open dialogue with your doctor. Dr. Smith respects my opinion. When I told him that I was feeling more than simply tired, he did some tests and found that I was anemic.

When I felt really sick this winter, he determined that a change in my medications had led to a fluid buildup around my heart. He put me back on diuretics and I’m feeling good now. And he made sure that I met with a cardiologist.

The clinic in Eagle Grove, a rural family medicine practice, is part of the UnityPoint Health Accountable Care Organization. I’m told it’s designed to improve communications between health care providers and their patients and provide more coordinated care to people enrolled in Medicare. It’s one of the ways the Affordable Care Act is promoting smarter care and lower costs all while putting patients first.

Health and Human Services Secretary Sylvia M. Burwell came to Fort Dodge recently to hear about the UnityPoint ACO experience and I was able to tell her about my story. I don’t know a whole lot about how ACOs work. But I like how I’m part of my health care team. I have a voice.

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