Community voice
Each day in the United States of America over 250 people die from drug overdoses and suicides. While the suicide rate in the country has climbed steadily during the first part of the 21st Century, the rate of drug overdoses has exploded at unprecedented levels during that same time period. The country is in the grips of an opioid epidemic that is devastating communities, shattering families, and overwhelming the capacity of local, state, and federal officials. The underlying medical conditions that directly lead to these deaths--mental illnesses and substance use disorders--are responsible for one of the most dire public health crises facing the nation today.
As the Affordable Care Act (ACA) awaits its fate before the Republican-controlled 115th Congress, it is important to note what the ACA has delivered for those affected by mental illness and addiction. The ACA and its implementing regulations requires all non-grandfathered individual and small-group (50 or fewer employees) health insurance plans to cover mental health and substance use disorder (behavioral health) treatment as part of the Essential Health Benefits package. In addition to the mandate that these insurance plans include behavioral health coverage, they must also comply with the Mental Health Parity and Addiction Equity Act (the Federal Parity Law), which was signed into law by President George W. Bush in 2008. The Federal Parity Law requires health insurance plans to cover behavioral health treatment in a way that is no more restrictive than how they cover other medical treatment. Previously, the Federal Parity Law only applied to large-group plans and Medicaid managed care plans. The ACA and the Federal Parity Law are critical for those with behavioral health conditions because prior to their enactment insurance plans either had very limited coverage for behavioral health treatment, or coverage was excluded entirely. Republicans in Congress and President Trump have maintained that a “repeal and replacement” of the ACA—or Obamacare, as they call it—is one of their top policy priorities. However, they have encountered resistance both from the public, and from members of their own party. As the party establishment, led by Speaker Paul Ryan (R-WI), huddles to craft legislation, other Republicans have already introduced legislation. The first bill introduced explicitly retains behavioral health coverage in the individual and small group market that meets the requirements of the Federal Parity Law. While that bill is not supported by the party at large, it is telling that the first ACA replacement bill identified behavioral health insurance coverage as something too important to eliminate. Maybe this should come as no surprise, though. Voters in many of the states and counties in the country most heavily affected by the opioid crisis gravitated to Donald Trump in the 2016 election. What this suggests is that Republicans need to consider all of the political ramifications of altering health insurance benefits for millions of Americans, especially those who live in states ravaged by overdoses and suicides. Democrats must also be aware of the potential political fallout that would occur if millions lost insurance coverage protections for behavioral health coverage. Why would Democrats have to worry? Aren’t they largely spectators in this process with no real power to stop it, you might ask? Actually, no. Thanks to something known as the Byrd Rule in the Senate, Republicans can’t simply repeal the entirety of the ACA through a budget reconciliation bill, which only requires 51 votes to pass. This is especially true for the health insurance market reforms—such as the mandate for behavioral health coverage—because they do not have a direct budgetary impact and therefore would likely be deemed “extraneous” and in violation of the Byrd Rule. What this means is that to eliminate the requirement that insurers cover behavioral health treatment, 60 votes are needed in the Senate, which means eight Democrats would have to go along. The most effective messaging points for anyone advocating that behavioral health treatment remains covered in the individual and small-group market are simple. They are three questions directed at Senators:
Those questions will not be easy to answer for any Senator who is thinking of voting Yea for a bill that will remove the landmark behavioral health insurance protections that were guaranteed to millions of Americans on March 23rd, 2010. Make sure that members of Congress understand that you expect them to answer those questions directly and truthfully. By Courtney Sartain Masters of Public Health Student Community Health & Prevention As a Drexel student, I understand the expectations of the University - that “all students . . . conduct themselves responsibly and in a manner that reflects favorably upon themselves and the University”. Much of that responsibility is laid out for students in a set of “Community Standards and Policies” at orientation including a drug policy that states, “[t]he possession and/or use of narcotics or drugs, other than those medically prescribed, properly used, and in the original container is prohibited”. Although each violation of the University’s drug policy is reviewed on an individual basis, depending on the case, “more or less severe sanctions may be imposed.” Additionally, “the primary response for use of possession of drugs will be separation from the University”. Violating the drug policy at the University can also result in suspension, loss of housing, counseling evaluation, community service, as well as other punishments. This policy aligns with state and federal laws that were intended to address an alarming drug culture that developed over the last century. Anecdotal evidence has suggested that although the University policy is not necessarily written in “zero-tolerance” language, it is the way the policy has been practiced. The policy discourages students from recreational drug use through strict punishment, but does not include information about drug substance use disorder or substance abuse problems as part of the practiced response. One student shared that at his violation hearing, he felt compelled to minimize his drug substance use disorder in order to maintain his status as a student. Had there been some offering of treatment or intervention, rather than only punishment, the University could have preempted a dangerous situation. Another student shared that although she enrolled in a rehabilitation program, she was summarily dismissed by the University rather than supported in her efforts to defeat her disease. After appealing that decision, she was allowed to continue her Drexel course of study, but was marked ineligible for a co-op, thus creating another hurdle to graduation and self-sufficiency. The University’s implementation of its drug policy misses a vital opportunity to support students by providing effective resources for those who face the prospect of substance use disorder. The possibility of expulsion makes it more likely that students will continue putting themselves in risky situations without considering short-term options and long-term solutions. For the past six months, I have been involved with a new student organization at Drexel called Dragons for Recovery. The student group was a brainchild of a close colleague in the MPH program. This Collegiate Recovery Community (CRC) at Drexel University is interested in inviting students, faculty, and staff to have conversations about the increasing social problems of substance use disorder and recovery in an effort to make the University’s policy and practice more effective and more aligned with the concept of substance use disorder as a disease of the brain. The campus group, along with many community practitioners and advocates, believes that a policy based on the concepts of harm reduction and acknowledgment of substance use disorder as a disease, would be of great benefit to students, faculty and staff at the University. Members of Dragons for Recovery, although a new group to the University Campus, have already begun their diligent work. A well-attended interest meeting and a communal showing of “The Anonymous People” in conjunction with UPenn’s CRC foreshadow the energy and commitment of Drexel students. Recent events included members attending a CRC Skiathon in Colorado, as well as provide training for students and others in the community with the goal of incorporating solutions for those facing the daunting prospect of substance use disorder. Perhaps the most impactful and immediate program sponsored by the CRC is Narcan training for Drexel personnel. Narcan, also known as Naloxone, is administered in the case of an opioid overdose. Dragons for Recovery recently held Narcan training, hosted by Prevention Point, in order to introduce this life-saving tool to students, faculty, and staff. While I encourage students, faculty and staff to start a conversation about de-stigmatizing substance use disorder and recovery, I challenge Drexel to implement a policy of opportunity, one that provides students with the tools and support to handle this public health crisis using current understandings of addition as disease, not a moral failing. While Drexel has legal responsibilities, my hope is that the policy will morph to be focused on harm reduction and self-help, instead of only punishment and stigma. Drexel is an excellent University – while I believe the dedication to support its students academically and professionally is unmatched, the University still has great potential to continue that support through aiding in personal perseverance and care of its students. By Tamela Luce, MPA Senior Program Officer HealthSpark Foundation, Colmar, PA Working at a foundation, I ask lots of questions. How does this service improve your clients’ lives? Why do you administer the program this way? How can we work together to enhance the entire system? My questions further my understanding of how things currently operate and gently encourage others to think about how to serve people more efficiently and effectively.
In 2015, I wrestled with this question: How can I get a group of unconnected service providers, with a range of resources and capacities, to come together regularly, learn how to improve their operations and begin to function as a system?” The answer, in part, was through the careful use of language to help establish buy-in and create a long-lasting network. I should back up. I am the Senior Program Officer for HealthSpark Foundation which uses a population health lens to improve the overall health and wellbeing of residents in Montgomery County, Pennsylvania. We work in three areas: health, housing/homelessness prevention and food security/nutrition. Since 2011, I have led HealthSpark’s efforts to advance the county’s emergency food system, comprised primarily of approximately 50 food pantries. Our pantries vary from small, all-volunteer run organizations in church basements to programs embedded within larger social service nonprofits with paid staff. HealthSpark’s vision is that all Montgomery County residents have access to healthy, nutritious food and we work toward that vision through the goal of strengthening the food safety net to reduce hunger in the county. As one of the wealthiest counties in the commonwealth, Montgomery County’s struggles with hunger are often masked. Most recent figures indicate 10% the population (81,000 citizens) is food insecure[1], meaning they do not get enough nutritious food for an active, healthy life. Many turn to pantries to help fill personal larders. Our emergency food providers are run by some of the most dedicated people you will ever meet. And many have been managing their pantry for 5, 10, 20 years and more. However, back in 2015, they were mostly disconnected from each other; there was no real “system” in place. To bring forth HealthSpark’s vision and goal, I knew we needed to build a countywide pantry network and establish an arena for ongoing learning. People have long convened to learn from one another. Known by many names – communities of practice, learning collaboratives, learning circles – collective learning has been prevalent in public health for many years and, more recently, in the nonprofit sector. Oftentimes, these learning collectives come together via internal champions and occasionally because of external stakeholders, including funders like HealthSpark. I spoke with several pantry managers about whether a venue for pantries to collectively learn from one another would be helpful. Interest was there, but could we create a group that would have longevity? We needed someone to direct the group and I was lucky enough to find a meeting planner/facilitator who also had years of experience working in emergency food in the region. Next, we needed buy-in from our pantries. I wanted this group to be by and for the providers, so we dubbed it the Pantry Peer Learning Circle (PLC). Unlike previous learning and technical assistance groups I had run that relied on outside experts to educate participants, discussions at PLC meetings were designed from the start to mine both challenges and solutions from pantry peers. Using the term “circle” communicates inclusion and a feeling of community (though we must be careful that the group does not become a “closed” circle that excludes potential participants). A planning committee of mostly pantry managers formed to brainstorm potential topics. This added layer of participation further created buy-in, especially as the facilitator and I developed meetings around their ideas. Even in the beginning, I carefully selected the language used in my emails about the PLC; organizations are invited attend their Peer Learning Circle to discuss topics they identified as being important to them and their colleagues. The PLC meets 4-5 times per year for a half-day. Our first convening in June 2015 was successful, but I didn’t know if the group would gel. We kept at it, and at our most recent meeting in September 2016 I saw pantry managers, staff and volunteers, many now loyal attendees, talking with others they didn’t know a year ago as if they were old friends. I overheard people following up on things others had said at previous meetings: “What was that client tracking software you use?” “How are you training volunteers?” “Where do you get your milk from?” On December 2nd, we will host our 7th PLC meeting. This one will focus on using data to improve operations. It won’t be as popular as September’s meeting on fundraising, but we will still get our core participants who will talk with their peers and take back ideas and tools to use in their own pantries. We have a long way to go to reach our vision of ensuring all Montgomery County residents have access to healthy, nutritious food. However, the Pantry Peer Learning Circle is helping these organizations, though the careful use of language, establish a network that will provide them with countless opportunities to learn from each other and ultimately improve the capacity of the county’s emerging emergency food system to better feed those in need. [1] Feeding America, Map the Meal Gap 2014 data |
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