Wayne County + Michigan Healthcare by Sean Carbary

WAYNE

COUNTY +

MICHIGAN

HEALTHCARE SEAN CARBARY DYLAN MAGLIOCCO

INTERMEDIATE VIS COM II PROJECT 2 - RESEARCH BOOK

HEALTHCARE

1 2 3 4 4

TABLE OF CONTENTS

INTRO

RESEARCH S.W.O.T.

SOURCES

Pg.6

OVERVIEW Insurance Timeline Stats

Pg.28

RESEARCH Expenses Mental Health Nutrition Opioid Crisis

Pg.124

ANALYSIS Strengths Weakness Opportunities Threats

Pg.134

LINKS References

OVERVIEW

PROJECT INTRO OVERVIEW RESEARCH SWOT SOURCES

PREFACE PROJECT OVERVIEW Healthcare means to maintain and improve physical and mental health through the use of medical services. Healthcare is a largely open topic that includes a multitude of processes and systems. Health insurance, Medicare, Medicaid, ACA, mental health, facilities, doctors, employees, prescription drugs, nutrition, overall health conditions and major hazards (cancer, stroke, smoking, AIDs, etc.). Starting off, we began looking into a lot of these systems and ideas within Michigan and eventually dug deeper in specific areas like Wayne County. Wayne county is a local area that has its own issues and concerns about healthcare. The goal of this research is to focus on a regional area, gather data, inform ourselves of our topic, and to compare overlaps, differences, and issues. Start broad with a large open topic and then funnel the research down into specific topics.

SEAN CARBARY CCS STUDENT JUNIOR

DYLAN MAGLIOCCO CCS STUDENT JUNIOR

OVERVIEW RESEARCH SWOT SOURCES

OVERVIEW WHAT IS HEALTHCARE?

WORD LIST

Before going deep into research we began broad research about healthcare and systems associated with it. We began by defining â&#x20AC;&#x153;healthcareâ&#x20AC;?, created word lists and systems associated with healthcare like health insurance. Then we created a timeline of the formation and the history of healthcare systems in America. From there we could research specific areas of interests or concerns within Michigan and Wayne.

Premium Deductible Copay Provider Physician Hospital Plans Inpatient Outpatient Pharmacy Medication Physical Therapy Cognitive Therapy System

OVERVIEW RESEARCH SWOT SOURCES

Coverage Protection Prevention Nurse Hospice Medicaid Medicare Obamacare Mobility Transportation Insurance Benefits Pre-existing Conditions Pediatrics

HEALTHCARE + The maintenance and improvement of physical and mental health, especially through the provision of medical services. MAJOR MEDICAL ISSUES

Child Birth Hospice Dental Braces Wisdom Teeth Asthma Cancer

Stroke Transplants Heart Disease Addiction Mental Illness Autism Auto Immune

HPB Obesity Malnutrition Allergies Diabetes STDâ&#x20AC;&#x2122;s HIV

INSURANCE HEALTH INSURANCE

HOW TO GET INSURANCE

TYPES

Health insurance is a type of insurance coverage that pays for medical and surgical expenses incurred by the insured. Health insurance can reimburse the insured for expenses incurred from illness or injury, or pay the care provider directly.

1. A group coverage plan at your job or your spouse or partner’s job.

TRADITIONAL

Health insurance helps you pay for medical services and sometimes prescription drugs. Once you purchase insurance coverage, you and your health insurer each agree to pay a part of your medical expenses, usually a certain dollar amount or percentage.

HEALTH INSURANCE COVERAGE PLATINUM - Covers 90% GOLD - Covers 80% SILVER - Covers 70% BRONZE - Covers 60% CATASTROPIC - Less than 60%

2. Your parents’ insurance plan, if you are under 26 years old. 3. A plan you purchase on your own directly from a health insurance company or through the Health Insurance Marketplace. 4. Government programs such as Medicare, Medicaid, or Children’s Health Insurance Program (CHIP). 5. The Veterans Administration or TRICARE for military personnel. 6. Your state, if it provides a health insurance plan. 7. Continuing employer coverage from your former employer, on a temporary basis under the Consolidated Omnibus Budget Reconciliation Act (COBRA).

OVERVIEW RESEARCH SWOT SOURCES

Traditional fee-for-service health insurance plans are usually the most expensive choice, but they offer you the most flexibility in choosing health care providers and doctors. HMO Health maintenance organizations (HMOs) offer lower co-payments and cover the costs of more preventive care, but your choice of health care providers is limited to those who are part of the plan. In order to see a specialist you must get referred first. PPO Preferred provider organizations (PPOs) offer lower co-payments like HMOs but give you more flexibility in selecting a provider. No referrals are need to seek specialist care.

MEDICARE

MEDICAID

AFFORDABLE CARE ACT

Medicare is a U.S. government program of hospitalization insurance and voluntary medical insurance for persons aged 65 and over and for certain disabled persons under 65.

Medicaid is a healthcare program that assists low-income families or individuals in paying for long-term medical and custodial care costs. Medicaid is a joint program, funded primarily by the federal government and run at the state level, where coverage may vary.

The Affordable Care Act (ACA) was designed to give individuals and families greater access to affordable health insurance options including medical, dental, vision, and other types of health insurance that they may not have been able to get on their own or through an employer. Under the ACA:

Medicaid is available only to individuals and families who meet specified criteria. Recipients must be legal permanent residents or citizens of the United States and may include adults with low income, their dependents, and people with specified disabilities.

You may be able to purchase health care through a state or federal marketplace that offers a choice of plans. Insurers can’t refuse coverage based on gender or a pre-existing condition. Lifetime and annual limits on coverage are eliminated. Young adults can stay on their family’s insurance plan until age 26. Seniors who hit the Medicare Prescription Drug Plan coverage gap or “donut hole” can get a discount on medications.

TIMELINE 1800’s

1900’s

The earliest formalized records in America’s history of healthcare are dated toward the end of the 19th century. The industrial revolution brought steel mill jobs to many U.S. cities, but the dangerous nature of the work led to more workplace injuries.

With the turn of the century came a push for organized medicine, led in part by the American Medical Association (AMA), which was growing stronger and gained 62,000 physicians during the coming decade. But because the working class wasn’t supportive of the idea of compulsory healthcare, the U.S. didn’t see the kind of groundswell that leading European nations would see soon after.

As these manufacturing jobs became increasingly prevalent, their unions grew stronger. In order to shield their union members from catastrophic financial losses due to injury or illness, they began to offer various forms of sickness protections to workers. At the time, there was very little organized structure and most decisions were made on a trial and error basis.

The 26th President of the United States, Theodore Roosevelt (19011909), believed health insurance was important because “no country could be strong whose people were sick and poor.” Even so, he didn’t lead the charge for stronger healthcare in America. Most of the initiative in the early 1900’s was led by organizations outside the government.

OVERVIEW RESEARCH SWOT SOURCES

1910â&#x20AC;&#x2122;s

One of the organizations heavily involved with advancing healthcare was the American Association of Labor Legislation (AALL), who drafted legislationtargeting the working class and low-income citizens (including children). Under the proposed bill, qualified recipients would see sick pay, maternity benefits, and a death benefit of $50.00 to cover funeral expenses. The AMA initially supported the bill, but some medical societies expressed objections, citing concerns over how doctors would be compensated. The fierce opposition caused the AMA to back down and ultimately pull support for the AALL bill. The fact that union leaders feared compulsory health insurance would weaken them, as a portion of their power came from being able to negotiate insurance benefits for union members. As one might expect, the private insurance industry also opposed the AALL Bill because they feared it would undermine their business.

If Americans received compulsory insurance through the government, they might not see the need to purchase additional insurance policies privately (especially life insurance), which could put them out of business or at the very least, cut into their profits. In the end, the AALL bill couldnâ&#x20AC;&#x2122;t garner enough support to move forward as global events turned American attention to the war effort. After the start of World War I, Congress passed the War Risk Insurance Act, which covered military servicemen in the event of death or injury. The Act was later amended to extend financial support to the servicemenâ&#x20AC;&#x2122;s dependents. The War Risk Insurance program essentially ended with the conclusion of the war in 1918, though benefits continued to be paid to survivors and their families.

TIMELINE 1920’s

1930’s

Post World War I, the cost of healthcare became a more pressing matter as hospitals and physicians began to charge more than the average citizen could afford. Seeing that this was becoming an issue, a group of teachers created a program through Baylor University Hospital where they would agree to pre-pay for future medical services (up to 21 days in advance). The resulting organization was not-for-profit and only covered hospital services. It was essentially the precursor to Blue Cross.

When the Great Depression hit in the 30’s, healthcare started to become a more heated debate. One might believe such conditions would create the perfect climate for compulsory, universal healthcare, but in reality, it did not. Rather, unemployment and “old age” benefits took precedence.

While “The Blues” (Blue Cross and Blue Shield) began to expand across the country, the 32nd President of the United States, Franklin Delano Roosevelt (1933-1945), knew healthcare would grow to be a substantial problem, so he got to work on a health insurance bill that included the “old age” benefits so desperately needed at the time.

OVERVIEW RESEARCH SWOT SOURCES

However, the AMA once again fiercely opposed any plan for a national health system, causing FDR to drop the health insurance portion of the bill. The resulting Social Security Act of 1935 created a system of “old-age” benefits and allowed states to create provisions for people who were either unemployed or disabled (or both).

1940’s

As the U.S. entered World War II after the attack on Pearl Harbor, attention fell from the health insurance debate. Essentially all government focus was placed on the war effort, including the Stabilization Act of 1942, which was written to fight inflation by limiting wage increases on workers. Since U.S. businesses were prohibited from offering higher salaries, they began looking for other ways to recruit new employees as well as incentivizing existing ones to stay. Their solution was the foundation of employer-sponsored health insurance as we know it today. Employees enjoyed this benefit, as they didn’t have to pay taxes on their new form of compensation and they were able to secure healthcare for themselves and their families. After the war ended, this practice continued to spread as veterans returned home and began looking for work. While this was an improvement for many, it left out vulnerable groups of people: retirees, those who are unemployed, those

unable to work due to a disability, and those who had an employer that did not offer health insurance. In an effort to not alienate at-risk citizens, some government officials felt it was important to keep pushing for a national healthcare system. The Wagner-Murray-Dingell Bill was introduced in 1943, proposing universal health care funded through a payroll tax. The bill was faced with intense opposition and eventually drowned in committee. When FDR died in 1945, Harry Truman (1945-1953) became the 33rd President of the United States. He took over FDR’s old national health insurance platform from the mid-30’s, but with some key changes. Truman’s plan included all Americans, rather than only working class and poor citizens who had a hard time affording care — and it was met with mixed reactions and debate in Congress. Some members of Congress called the plan “socialist” and suggested

that it came straight out of the Soviet Union, adding fuel to the Red Scare that was already gripping the nation. Once again, the AMA took a hard stance against the bill, also claiming the Truman Administration was towing “the Moscow party line.” The AMA even introduced their own plan, which proposed private insurance options, departing from their previous platform that opposed third-parties. Even after Truman was re-elected in 1948, his health insurance plan died as public support dropped off and the Korean War began. Those who could afford it began purchasing health insurance plans privately and labor unions used employer-sponsored benefits as a bargaining chip.

TIMELINE 1950’s

As the government became primarily concerned with the Korean War, the national health insurance debate was tabled, once again. While the country tried to recover from its third war in 40 years, medicine was moving forward. It could be argued that the effects of Penicillin in the 40’s opened people’s eyes to the benefits of medical advancements and discoveries. In 1952, Jonas Salk’s team at the University of Pittsburgh created an effective Polio vaccine, which was tested nationwide two years later and was approved in 1955. During this same time frame, the first organ transplant was performed when Dr. Joseph Murray and Dr. David Hume took a kidney from one man and successfully placed it in his twin brother. Of course, with such leaps in medical advancement, came additional cost — a story from the history of healthcare

that is still repeated today. During this decade, the price of hospital care doubled, again pointing to America’s desperate need for affordable healthcare. But not much changed in the health insurance landscape.

OVERVIEW RESEARCH SWOT SOURCES

1960’s

By the 1960, the government started tracking National Health Expenditures (NHE) and calculated them as a percentage of Gross Domestic Product (GDP). At the start of the decade, NHE accounted for 5 percent of GDP. When John F. Kennedy (1961-1963) was sworn in as the 35th President of the United States, he wasted no time at all on a healthcare plan for senior citizens. Seeing that NHE would continue to increase and knowing that retirees would be most affected, he urged Americans to get involved in the legislative process and pushed Congress to pass his bill. But in the end, it failed miserably against harsh AMA opposition and again — fear of socialized medicine. After Kennedy was assassinated on November 22, 1963, Vice President Lyndon B. Johnson (1963-1969) took over as the 36th President of the United States. He picked up where

Kennedy left off with a senior citizen’s health plan. He proposed an extension and expansion of the Social Security Act of 1935, as well as the Hill-Burton Program (which gave government grants to medical facilities in need of modernization, in exchange for providing a “reasonable” amount of medical services to those who could not pay).

President’s desk. Johnson signed the Social Security Act of 1965 on July 30 of that year, with President Harry Truman sitting at the table with him. This bill laid the groundwork for healthcare systems, what we now know as Medicare and Medicaid.

Johnson’s plan focused solely on making sure senior and disabled citizens were still able to access affordable healthcare, both through physicians and hospitals. Though Congress made hundreds of amendments to the original bill, it did not face nearly the opposition that preceding legislation had — one could speculate as to the reason for its easier path to success, but it would be impossible to pinpoint with certainty. It passed the House and Senate with generous margins and went to the

TIMELINE

OVERVIEW RESEARCH SWOT SOURCES

1970’s

By 1970, NHE accounted for 6.9 percent of GDP, due in part to “unexpectedly high” Medicare expenses. Because the U.S. had not formalized a health insurance system (it was still just people who could afford it buying insurance), they didn’t really have any idea how much it would cost to provide healthcare for an entire group of people — especially an older group who is more likely to have health problems. Nevertheless, this was quite a leap in a ten year time span, but it wouldn’t be the last time we’d see such jumps. This decade would mark another push for national health insurance however, this time from unexpected places. Richard Nixon (1969-1974) was elected the 37th President of the United States in 1968. As a teen, he watched two brothers die and saw his family struggle through the 1920’s to care for them. To earn extra money for the household, he worked as a janitor. When it came time to apply for

colleges, he had to turn Harvard down because his scholarship didn’t include room and board expenses. Entering the White House as a Republican, many were surprised when he proposed new legislature that strayed from party lines in the healthcare debate. With Medicare still fresh in everyone’s minds, it wasn’t a stretch to believe additional healthcare reform would come hot on its heels, so members of Congress were already working on new plans. In 1971, Senator Edward (Ted) Kennedy proposed a single-payer plan (a modern version of a universal, or compulsory system) that would be funded through taxes. Nixon didn’t want the government reaching so far into Americans’ lives, so he proposed his own plan, which required employers to offer health insurance to employees and even provided subsidies to those who had trouble affording the cost of insurance.

Nixon believed that basing a health insurance system in the open marketplace was the best way to strengthen the existing makeshift system of private insurers. In theory, this would have allowed the majority of Americans to have some form of health insurance or coverage. People of working age (and their immediate families) would have insurance through their employers and then they’d be on Medicare when they retired. Lawmakers believed the bill satisfied the AMA because doctors’ fees and decisions would not be influenced by the government. Kennedy and Nixon ended up working together on a plan, but in the end, Kennedy buckled under pressure from unions and he walked away from the deal — a decision he later said was “one of the biggest mistakes of his life.” Shortly after negotiations broke down, Watergate hit and all the support Nixon’s healthcare plan had

1980’s

garnered completely disappeared. The bill did not survive his resignation and his successor, Gerald Ford distanced himself from the scandal. However, Nixon was able to accomplish two healthcare-related tasks. The first was an expansion of Medicare in the Social Security Amendment of 1972 and the other was the Health Maintenance Organization Act of 1973 (HMO), which established some order in the healthcare industry. But by the end of the decade, American medicine was considered in a“crisis,” from economic recession and heavy inflation.

By 1980, NHE accounted for 8.9 percent of GDP, an even larger leap than the decade prior. Under the Reagan Administration (1981-1989), regulations loosened across the board and privatization of healthcare became increasingly common. In 1986, Reagan signed the Consolidated Omnibus Budget Reconciliation Act (COBRA), which allowed former employees to continue to be enrolled in their previous employer’s group health plan — as long as they agreed to pay the full premium (employer portion plus employee contribution). This provided health insurance access to the recently unemployed who might have otherwise had difficulty purchasing private insurance (due to a preexisting condition, for example).

TIMELINE

OVERVIEW RESEARCH SWOT SOURCES

1990’s

By 1990, NHE accounted for 12.1 percent of GDP the largest increase thus far in the history of healthcare. Like others before him, the 42nd President of the United States, Bill Clinton, saw that this rapid increase in healthcare expenses would be damaging to the average American and attempted to take action. Shortly after being sworn in, Clinton proposed the Health Security Act of 1993. It proposed many similar ideas to FDR and Nixon’s plans — a mix of universal coverage while respecting the private insurance system that had formed on its own in the absence of legislation. Individuals could purchase insurance through “state-based cooperatives,” companies could not deny anyone based on a pre-existing condition, and employers would be required to offer health insurance to full-time employees. Multiple issues stood in the way of the Clinton plan, including foreign affairs, the

complexity of the bill, an increasing national deficit, and opposition from big business. After a period of debate toward the end of 1993, Congress left for winter recess with no conclusions leading to the bill’s quiet death. In 1996, Clinton signed the Health Insurance Portability and Accountability Act, which established privacy standards for individuals. It also guaranteed that medical records would be available upon their request and placed restrictions on how preexisting conditions were treated in group health plans. The final healthcare contribution from the Clinton Administration was part of the Balanced Budget Act of 1997. It was called the Children’s Health Insurance Program (CHIP) and it expanded Medicaid assistance to “uninsured children up to age 19 in families with incomes too high to qualify them for Medicaid.”

CHIP is run by each individual State and is still in use today. In the meantime, employers were trying to find ways to cut back on healthcare costs. In some cases, this meant offering HMOs, which by design, are meant to cost both the insurer and the enrollee less money. Typically this includes cost saving measures, such as narrow networks and requiring enrollees to see a primary care physician (PCP) before a specialist. Generally speaking, insurance companies were trying to gain more control over how people received healthcare. This strategy worked overall - the 90’s saw slower healthcare cost growth.

2000’s

By the year 2000, NHE accounted for 13.3 percent of GDP — just a 1.2 percent increase over the past decade. When George W. Bush (2001-2009) was elected the 43rd President of the United States, he wanted to update Medicare to include prescription drug coverage. This idea eventually turned into the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (sometimes called Medicare Part D). Enrollment was (and still is) voluntary, although millions of Americans use the program. The history of healthcare slowed down at that point, as the national healthcare debate was tabled while the U.S. focused on the increased threat of terrorism and the second Iraq War. It wasn’t until election campaign mumblings began in 2006 and 2007 that insurance worked its way back into the national discussion. When Barack Obama (2009-2017) was elected the 44th President of

the United States in 2008, he wasted no time getting to work on health care reform. He worked closely with Senator Ted Kennedy to create a new healthcare that mirrored the one Kennedy and Nixon worked on.

going through multiple revisions, but ultimately, it passed and moved to the President’s desk.

Like Nixon’s bill, it mandated that applicable large employers provide health insurance, in addition to requiring that all Americans carry health insurance, even if their employer did not offer it. The bill would establish an open Marketplace, on which insurance companies could not deny coverage based on pre-existing conditions. American citizens earning less than 400 percent of the poverty level would qualify for subsidies to help cover the cost. It wasn’t universal or single-payer coverage, but instead used the existing private insurance industry model to extend coverage to millions of Americans. The bill circulated the House and the Senate for months,

TIMELINE

OVERVIEW RESEARCH SWOT SOURCES

2010’s - NOW

While the country focused on the second Iraq War, the cost of healthcare took another leap. By 2010, NHE accounted for 17.4 percent of GDP. This period of time would bring a new, but divisive chapter in the history of healthcare in America. On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) into law. Because the law was complex and the first of its kind, the government issued a multi-year rollout of its provisions. In theory, this should have helped ease insurance companies (and individuals) through the transition, but in practice, things weren’t so smooth. The first open enrollment season for the Marketplace started in October 2013 and it was rocky, to say the least. Nevertheless, 8 million people signed up for insurance through the ACA Marketplace during the first open

enrollment season. The numbers increased to 11.7 million in 2015 and it’s estimated that the ACA has covered an average of 11.4 million annually ever since. It’s no secret that the ACA was met with heavy opposition for a variety of reasons (the individual mandate and the employer mandate being two of the most hotly contested). Some provisions were even taken before the Supreme Court on the basis of constitutionality. In addition, critics highlighted the problems with healthcare.gov as a sign this grand “socialist” plan was destined to fail. Regardless of the controversy, it could be argued that the most helpful part of the ACA was its pre-existing condition clause. Over the course of the 20th century, insurance companies began denying coverage to individuals with pre-existing conditions, such as asthma, heart attacks, strokes, and AIDS. The exact point when pre-

existing conditions were cited in the history of our healthcare is debatable, but very possibly, it occurred as forprofit insurance companies popped up across the landscape. Back in the 20’s, not-for-profit Blue Cross charged the same amount, regardless of age, sex, or pre-existing condition, but eventually, they changed their status to compete with the newcomers. And as the cost of healthcare increased, so did the number of people being denied coverage. Prior to the passing of the ACA, it’s estimated that one in seven Americans were denied health insurance because of a pre-existing condition, the list of which was extensive and often elusive. In addition, the ACA allowed for immediate coverage of maternal and prenatal care, which had previously been far more restrictive in private insurance policies. Usually, women had to pay an additional fee for maternity coverage for at least 12

History Shall Repeat Itself

months prior to prenatal care being covered — otherwise, the pregnancy was viewed as a pre-existing condition and services involving prenatal care (bloodwork, ultrasounds, check-ups, etc) were not included in the policy.

Since Donald Trump was sworn in as the 45th President of the United States on January 20, 2017, many have been questioning what will happen with our healthcare system, specifically, what will happen to ACA, since Trump ran on a platform of “repealing and replacing”. As open enrollment for 2017 drew to a close, it became apparent to lawmakers that either repealing or replacing the ACA would be no easy task. If they were to repeal the bill, what would happen to the 11 million Americans currently insured through the Marketplace? If they come up with a replacement plan, what does that look like? What changes would be made? Will there be a Marketplace? Will insurance companies be able to deny coverage based on pre-existing conditions again? There are plenty of questions that need answered and it doesn’t seem like a decision will be reached anytime soon, but one thing is for sure: changes will be made. What those changes will be depends on Congress, Trump, the new Secretary of Health and Human Services, Tom Price — and you, the voter. The history of healthcare in America will continue to evolve and it will be interesting to see where this administration takes us and the affects their plan will have on Americans. Regardless, we’ll have to keep an eye on the national health expenditure numbers. According to the latest data available, NHE was 17.8 percent of GDP in 2015, signaling slower growth than the previous decade, but only time will tell the full story.

STATISTICS MICHIGAN POPULATION

9.9 Million

HEALTH ISSUES

White Black Hispanic Asian

7.49 Million - 77% 1.36 Million - 13% 485,972 - 4% 292,298 - 3%

Obesity 38.5% Diabetes 11.2% Smoking 20.4% Drug Deaths 2,317

ECONOMY Median Age Median Income Poverty Rate

39.7 $51,084 15.8%

SUPPORT No Healthcare 6.3% Food Assistance 1,314,863 - 13% Disability 3,507 Child Development 66,598 Medicaid Eligible 1,801,747 - 18% CLINICIAN TO PATIENT RATIO Primary Care Mental Health

1-80 1-216

OVERVIEW RESEARCH SWOT SOURCES

WAYNE COUNTY POPULATION

1.76 Million

HEALTH ISSUES

White Black Hispanic Asian

875,992 - 50% 685,441 - 39% 101,015 - 6% 56,577 - 3%

Obesity 34.2% Diabetes 24% Smoking 20.9% Drug Deaths 635

ECONOMY Median Age Median Income Poverty Rate

37.8 $41,557 24.8%

SUPPORT No Healthcare 8.4% Food Assistance 430,820 - 24% Disability 970 Child Development 20,236 Medicaid Eligible 492,036 - 28% CLINICIAN TO PATIENT RATIO Primary Care Mental Health

1-66 1-239

RESEARCH

WAYNE + MICHIGAN HEALTH OVERVIEW RESEARCH SWOT SOURCES

EXPENSES AMERICA’S HEALTH CARE PRICES ARE OUT OF CONTROL

USA CH ES UK

Sarah Kliff + Soo Oh 6/19/2016 SUMMATION +

Common health expenses in the U.S. compared to other countries. The U.S. pays at least double than the other countries in most medial costs, sometimes more.

Humira is an injectable medication used to treat multiple autoimmune diseases ranging from rheumatoid arthritis to psoriasis to ulcerative colitis and it’s one of the best-selling drugs in American history. In 2014 alone, millions of Americans spent a combined $6.5 billion on Humira. But we probably didn’t have to. While Americans paid an average price of $2,669 for Humira, the Swiss were able to buy the exact same drug for $822 — and in the United Kingdom, patients got it for $1,362. If the United States paid what the Swiss paid for the arthritis drug, we would have spent $2 billion on Humira in 2014 rather than $6.5 billion There’s nothing different about the Humira that we bought in the United States and the drug the Swiss bought except that in the United States, we’re terrible at negotiating a good deal on any medical service. “It’s exactly the same product, but, in terms of the American patient, you’re just paying double or more the price for no more health gain,” says Tom Sackville, chief executive of the International Federation of Health Plans. Every two years, his group publishes a report that compares health care prices in different countries.

OVERVIEW RESEARCH SWOT SOURCES

United States Switzerland Spain United Kingdom

And it shows that Humira isn’t some weird anomaly; nearly every procedure or drug costs way more in the United States. See for yourself in these charts:

$2,669

USA

$32,114

USA

$3,930

USA

HUMIRA, a medication for multiple forms of arthritis, skin conditions, and inflammatory bowel diseases, costs three times as much in the United States as in Switzerland.

HARVONI, cures hepatitis C. It also costs $10,000 more in the US than anywhere else.

Need to take the cancer drug AVASTIN? It will cost nine times more in the United States than in Britain.

$1,119

$5,220

$15,930

USA

An MRI costs twice as much here as in Switzerland.

USA

A DAY IN A HOSPITAL costs $5,220 here — versus $424 in Spain.

USA

Consider APPENDIX REMOVAL in Australia — it will be about $12,000 cheaper.

EXPENSES

OVERVIEW RESEARCH SWOT SOURCES

AMERICANS USE THE DOCTOR LESS THAN PEOPLE IN OTHER COUNTRIES. The United States is routinely the most expensive place to buy medical care, whether that’s a Humira pen or a knee replacement or an MRI scan. There are a handful of exceptions to the rule: The US does have colonoscopies that are cheaper than in New Zealand or the United Kingdom. CT scans we come in slightly cheaper than Britain. But aside from those examples, it’s generally a safe bet that the highest prices for medical care can be found in America. The IFHP report undercut a common misconception about American health care: that it’s more expensive because we use more of it. Americans actually tend to use slightly less health care than people living elsewhere. We go to the doctor less, and have fewer hospitals per capita than most European countries but pay more. Americans spend more for health care largely because of the prices. Most other countries have some central body that negotiates prices with hospitals and drug manufacturers. Sackville, who used to work for Britain’s health care system, recalls that it had a unit of 14 people whose job was getting drug manufacturers to give a better deal on prescriptions.

That unit of 14 is essentially buying in bulk for a country of 63 million people – and can successfully ask for steep discounts in return. The United States doesn’t have that type of agency. Every insurance plan negotiates individually with hospitals, doctors, and pharmaceutical company to set prices. Insurers in the United States don’t, as these charts show, get a bulk discount. Instead, our fragmented system means that Americans pay more for every type of health care that IFHP measured. “You could say that American health care providers and pharmaceuticals are essentially taking advantage of the American public because they have such a fragmented system, the system is so divided, it’s easy to conquer.” What would make these charts look different? How could the United States end up more in the middle of the pack? The simplest answer is that it could start handling drug negotiations like other countries, and set up a body that negotiates prices for the country. Right now we leave those negotiations up to health insurance plans. And the health insurance plans tend to lose. Defenders of the American system argue that these types of price controls stifle

innovation. Many say that our higher spending creates financial incentives for drug companies to come up with wonderful new drugs. And they’re probably right: More money paid to pharmaceutical companies does give them additional liberty to experiment and come up with new treatments. But that means we’re paying higher prices to subsidize drugs for the rest of the world. It also means that some of the treatments pharmaceutical companies develop will be out of reach of many Americans when they come to market.

$10,808

USA

$16,106

USA

$3,530

At this point, it will be no surprise that a NORMAL DELIVERY in the United States is quite expensive too.

The same is true for C-SECTION procedures — they cost twice as much here as in Australia.

$78,318

$28,184

USA

BYPASS SURGERY costs $78,318 here, versus $24,059 in the UK.

USA

And for CATARACT SURGERY — it’s more expensive in the United States than anywhere else.

The same goes for another common procedure, KNEE REPLACEMENTS.

EXPENSES THE MICHIGAN COUNTIES MOST VULNERABLE IF OBAMACARE IS REPEALED

Nancy Derringer + Mike Wilkinson 1/12/2017

SUMMATION + Wayne county is would be affected the most is the ACA was repealed. There’s been debate about repealing or reforming the ACA but no solutions have been made yet.

OVERVIEW RESEARCH SWOT SOURCES

Hundreds of thousands of state residents would likely be affected by a repeal of the Affordable Care Act, including those in counties that went hard for the law’s critic-inchief, President-Elect Donald Trump, according to a Bridge Magazine analysis of government data. The implications of an immediate repeal of the ACA could be felt by nearly 1-in-10 Michigan residents, and as much as 13 percent of the population in places as different from one another as the Detroit-area and rural Emmet County. Consider: In Wayne County, dominated by Democraticheavy Detroit, 12.7 percent of county residents receive health care through a combination of ACA enrollment or Medicaid expansion. In Cheboygan County, at the top of the mitt, where Trump trounced Democratic nominee Hillary Clinton by a 2-to-1 margin, 13.1 % of residents depend on ACA coverage or Medicaid expansion. If the Republican-led Congress, with a likeminded president, also change the way that traditional Medicaid is funded, as many as two million Michiganders could be impacted by Washington’s dramatic health-care changes, enrollment data show. IMPACT OF ACA REPEAL IN MICHIGAN Congress is considering repeal of the Affordable Care Act and major changes to Medicaid. Nearly a million people in Michigan get their health coverage through the ACA or Medicaid expansion, helping cut in half the percent of people who don’t have health insurance. Click or tap on a county or congressional district to see how many people are covered by Medicaid expansion and the ACA. Trump is pushing Congress to immediately repeal “Obamacare” and congressional leaders have already begun taking votes to dismantle President Obama’s signature domestic legislative achievement. It remains unclear whether Congress can agree on a plan to replace it immediately or at some point in the future.

EXPENSES That uncertainty could leave many Michiganders facing the prospect of losing their health coverage, at least temporarily untill they come up with a new solution. Bridge asked the state’s congressional delegation whether and how the ACA should be changed or repealed. Republicans, who hold 9 of the state’s 14 congressional seats, generally indicated they would move quickly to dump the law though, notably, no Republican spelled out whether they are willing to ditch Obamacare without a concrete plan to replace it. “The president’s health-care law has led to double-digit premium increases, rising deductibles, and dwindling choices for consumers,” said one, Rep. Tim Walberg, R-Tipton, in a statement. “Obamacare is collapsing and families who are hurting need relief. To fix this broken system, we need to repeal Obamacare and have a stable transition to patient-centered health care solutions that give families more choices and lower costs.”

Half the state’s delegation – four Republicans and three Democrats – responded to questions posed by Bridge this week. Both U.S. Senators, Democrats Gary Peters and Debbie Stabenow, defended the ACA and, like others in their party, said they do not favor repeal but largely agree that the ACA can be improved, though they too weren’t terribly specific on how. “The Affordable Care Act must be preserved. The evidence of its benefits are clear in our state,” Rep. Sandy Levin, D-Royal Oak, said in statement. “The protections in the law are also vital so that no one can be denied coverage because of a pre-existing condition or women are not charged more for their care.” Republican congressmen Fred Upton of St. Joseph, Mike Bishop of Rochester and Paul Mitchell of Dryden sent general answers that criticized the ACA but offered no specific plans on how best to repeal, replace or change any elements of it.

OVERVIEW RESEARCH SWOT SOURCES

DEMS: REPEAL NOT THE ANSWER Since the ACA went into effect in 2013, the percentage of state residents without health insurance fell from 11 percent to 6.1 percent, according to U.S. Census data from 2015. It’s likely even lower today though, as Republicans are quick to note, premiums for ACA-bought policies continue to rise. “The Affordable Care Act is not perfect but it has provided a significant benefit to working families across Michigan,” Rep. Debbie Dingell, D-Dearborn, said in response to Bridge’s inquiry. “We cannot afford to go backwards, and I will be fighting tooth and nail to protect the health care coverage” of those receiving coverage through the ACA. More than 630,000 people were added to the state’s Medicaid rolls since early 2014, when the Michigan Legislature voted to expand coverage for the poor. The ACA offered additional federal funding to states to cover those making up $33,000 for a family of four or $16,000 for a single person. (The limit for Medicaid is just below $25,000 for a family of four and $12,000 for an individual.) The plan, approved by the Michigan Legislature with the vast majority of Democratic legislators and a minority of Republicans, went into effect in early 2014 and has seen hundreds of thousands sign up across the state. In many northern Michigan counties, the expansion doubled the number of people eligible for Medicaid. Then, beginning in 2014, residents were able to buy private health insurance through the federal exchanges. As of late last year, more than 345,000 Michigan residents were covered by ACA-bought policies. To ACA supporters, the number of beneficiaries – nearly a million across the state – should give Congress pause before it makes major changes to a program that benefits so many in Michigan and across the country.

“One would hope that the congressional delegation is responsive to its constituents,” said Marianne UdowPhillips, director of the Center for Healthcare Research & Transformation, a nonpartisan health care research center based at the University of Michigan.

A VOTE FOR CHANGE

BENEFITS FROM…SOMEWHERE

In Oscoda County, between Grayling and Lake Huron in northern Michigan, more than a quarter of residents get Medicaid – traditional or through the expansion – or bought a policy through the ACA. It’s one of the highest rates in the state. So too is the support it gave Trump, who received 70 percent of the county vote; Trump performed better in only two other Michigan counties.

Udow-Phillips, a former director of the Michigan Department of Human Services, acknowledged that the ACA has problems, including premium increases averaging nearly 17 percent, and needs to be amended. But she said it might get more support if more of its beneficiaries were aware of who they are. She said some who benefit from Medicaid expansion don’t know that they are benefitting from “Obamacare” in part because Michigan calls its expansion program Healthy Michigan” with no mention of Medicaid or the ACA. “A lot of people didn’t realize they got coverage because of the Affordable Care Act,” she said. “Communication around this law has been terrible by advocates for the law.” Indeed, news stories have appeared around the country indicating that some recipients don’t know the coverage they now have is a result of the ACA. “I guess we really didn’t think about that, that he was going to cancel that or change that or take it away. I guess I always just thought that it would be there,” Debbie Mills, a Trump voter in Kentucky, told Vox. “I was thinking that once it was made into a law that it could not be changed, but I guess it can? Yes?” The Senate took the first steps toward repeal this week, voting 51-48 to use the budget process to begin defunding the law. However, no plan to replace it has emerged, although individual pieces of a potential new health-care structure have been talked about for years. Republicans in charge of writing legislation to defund the ACA say no final decisions have been made, despite a Jan. 27 action deadline set by the incoming administration.

In Michigan, some counties with the highest Medicaid expansion and ACA usage gave Trump some of his largest victory margins (by just over 10,000 votes).

Conversely, urban areas like Wayne County, where more than 30 percent of residents get Medicaid (traditional or through expansion) or bought an ACA policy, went for Democratic nominee Hillary Clinton in big numbers. She promised to preserve the ACA. Charles Gaba, a Bloomfield Hills web developer, began collecting and disseminating data on the ACA in 2013 and has become a reliable source for ACA data to both the media and politicians. He estimates that two-thirds of those who bought a private policy through the ACA and all of those who are on the Healthy Michigan plan could be directly affected by repeal. And that doesn’t count roughly one million state residents who benefit from traditional Medicaid coverage, which could also see substantial changes. Georgia Republican Rep. Tom Price, Trump’s pick as secretary of health and human services, has advocated turning Medicaid into a block grant program similar to welfare, which would send money to the states while giving them greater flexibility on how to spend it. Those plans make some advocates for the poor nervous, in part because of how states, including Michigan, have historically handled other block grant programs. Bridge wrote last year about how some block grant money for the poor ended up funding scholarships at private colleges in the state for more affluent students.

EXPENSES CHANGE IS COMING For critics of the ACA, Trump’s election has created an opportunity to focus on those who’ve been harmed because their premiums rose sharply, their insurance shifted to higher deductibles, or they lost job opportunities because of high insurance costs. “It’s very easy when you talk about the possibility of repeal that you’ll be able to identify and swing a camera and find some people who would lose their coverage. It’s true and unfortunate. (But) right now the existence of the law has some very serious negative effects on a lot of people,” said Robert Graboyes, a senior research fellow focusing on health care at the Mercatus Center, a market-oriented research center at George Mason University in Virginia. Noting that the plan has been far more expensive than expected, Graboyes said he is hopeful the ACA’s successor will tackle cost. If regulatory controls on new drugs and treatments are altered, pharmaceutical costs could fall, he said. If hospitals are allowed to compete more, other costs could come down. He said savings from a “market approach” could pay for the health care coverage of millions. Instead, he said even Republican solutions are focused largely on how bills are paid – through insurance – rather than how those bills are comprised. “And as long as all we talk about is insurance and the demand side we’re not going to get out of it,” Graboyes said. “But I’m confident that ultimately we will. To some extent we don’t have a choice.” No clear proposal has emerged from the Republicans on what they plan to do. Price hasn’t been confirmed yet and Trump isn’t inaugurated until Jan. 20. Until they do or until a bill gets enough support in Congress, what happens next is almost anyone’s guess. “I think it’s very, very hard to know at this point exactly what they’re going to propose,” Udow-Phillips said. “I don’t think they know what they’re going to propose yet.”

OVERVIEW RESEARCH SWOT SOURCES

EXPENSES THE RISING COST OF HEALTH CARE BY YEAR AND ITS CAUSES Kimberly Amadeo 10/26/2017

SUMMATION + Medical costs have constantly risen and this timeline details reasons for the inflation.

OVERVIEW RESEARCH SWOT SOURCES

In 2015, U.S. health care costs were $3.2 trillion. That makes health care one of the country’s largest industries, equaling to 17.8 percent of gross domestic product. In comparison, health care cost $27.2 billion in 1960, just 5 percent of GDP. That translates to an annual health care cost of $9,990 per person in 2015 versus just $146 per person in 1960. Health care costs have risen faster than the annual income. Health care consumed 4 percent of earnings in 1960 compared to 6 percent in 2013. The two causes of this massive increase were government policy and lifestyle changes. First, the United States relies on company-sponsored private health insurance. The government created programs like Medicare and Medicaid to help those without insurance. These programs spurred demand for health care services. That gave providers the ability to raise prices. Other efforts to reform health care and cut costs raised them instead. Second, chronic illnesses, such as diabetes and heart disease, have increased. They are responsible for 85 percent of health care costs. Almost half of all Americans have at least one of them. They are expensive and difficult to treat. As a result, the sickest 5 percent of the population consume 50 percent of total health care costs. The healthiest 50 percent only consume 3 percent of the nation’s health care costs. Most of these patients are Medicare patients. The U.S. medical profession does a heroic job of saving lives. But it comes at a cost. Medicare spending for patients in the last year of life is six times greater than the average. Care for these patients costs one-fourth of the Medicare budget. In their last six months of life, these patients go to the doctor’s office 29 times on average. In their last month of life, half go to the emergency room. One-third wind up in the intensive care unit. One fifth undergo surgery. GOVERNMENT POLICY Between 1960 and 1965, health care spending increased by an average of 8.9 percent a year. That’s because health insurance expanded. As it covered more people,

the demand for health care services rose. By 1965, households paid out-of-pocket for 44 percent of all medical expenses. Health insurance paid for 24 percent.

immigrants, children and pregnant women. Prescription drug costs rose by 12.1 percent a year. Home health care prices increased by 18.3 percent per year.

From 1966 to 1973, health care spending rose by an average of 11.9 percent a year. Medicare and Medicaid covered more people and allowed them to use more health care services. Seniors citizens were able to move into expensive nursing home facilities. As demand increased, so did prices. Health care providers put more money into research. It created more innovative, but expensive, technologies.

Between 1993 and 2010, prices rose by an average of 6.4 percent a year. In the early 1990s, health insurance companies tried to control costs by spreading the use of HMOs once again. Congress then tried to control costs with the Balanced Budget Act in 1997. Instead, it forced many health care providers out of business. Because of this, Congress relented on payment restrictions in the Balanced Budget Refinement Act in 1999 and the Benefits Improvement and Protection Act of 2000.

Medicare helped create an overreliance on hospital care. Emergency room treatment is very expensive, making up one-third of all health care costs in America. By 2011, there were 136 million emergency room visits. An astonishing one out of five adults use the emergency room each year. In 1971, President Nixon implemented wage-price controls to stop somewhat mild inflation. At first, artificially low health care prices created higher demand. In 1973, Nixon authorized health maintenance organizations to cut costs. These prepaid plans restricted users to a particular medical group. The HMO ACT of 1973 provided millions of dollars in start up funding for HMOs. It also required employers to offer them when available. In 1973, Nixon completely abandoned the gold standard. As the dollarâ&#x20AC;&#x2122;s value plummeted, it unleashed double-digit inflation. Health care costs rose at the same rates as the infliation. From 1974 to 1982, health care prices rose by an average of 14.1 percent a year for three reasons. First, prices rebounded after the wage-price controls expired in 1974. Second, Congress enacted the Employee Retirement Income Security Act of 1974. It exempted corporations from state regulations and taxes if they self-insured. Companies took advantage of these lower-cost and flexible plans. Third, home health care took off, growing by 32.5 percent a year. Between 1983 and 1992, health care costs rose by an average of 9.9 percent each year. Congress expanded Medicaid to include illegal

After 1998, people rebelled and demanded more choice in providers. As demand increased again, so did prices. This time, pharmaceutical companies invented new types of prescription drugs. They advertised straight to consumers and created additional demand. In 2003, the Medicare Modernization Act added Medicare Part D to cover prescription drug coverage. It also changed the name of Medicare Part C to the Medicare Advantage program. The number of people using those plans tripled to 17.6 million by 2016. Those costs rose faster than the cost of Medicare itself. The nationâ&#x20AC;&#x2122;s reliance on corporate private health insurance left many people without a primary care physician. By 2009, half of the people (46.3 percent) who used a hospital said they went because they had no other place to go for health care. The The Emergency Medical Treatment and Active Labor Act required hospitals to treat anyone who showed up in the emergency room. These uninsured patients cost hospitals a staggering $10 billion a year. The hospitals passed this cost along to Medicaid.

EXPENSES CHRONIC DISEASES The second cause of rising health care costs is an epidemic of preventable health crises. The four leading causes of death are heart disease, cancer, chronic obstructive pulmonary disorder, and stroke. Chronic diseases cause all of them. It means they can either be prevented or would cost less to treat if caught in time. Risk factors for heart disease and strokes are poor nutrition and obesity. Smoking is a risk factor for lung cancer (the most common type) and COPD. Obesity is also a risk factor for the other common forms of cancer. These diseases cost an extra $7,900 each. That’s five times more than a healthy person. The average cost of treating diabetes, for example, is $26,971 per family. These diseases are difficult to manage because patients get tired of taking the various medications. Those who cut back find themselves in the emergency room with heart attacks, strokes and other complications. (Source: “The Impact of Chronic Diseases on Health Care,” For a Healthier America, 2014.) HOW THE ACA SLOWED THE RISE OF HEALTH CARE COSTS By 2009, rising health care costs consumed the federal budget. Medicare and Medicaid cost $676 billion. That’s 10.4 percent of the total budget. Payroll taxes only cover half of Medicare and none of Medicaid. This so-called mandatory spending also included federal and veterans’ pensions, welfare and interest on the debt. It consumed 60 percent of the federal budget. What’s even worse, retiring Baby Boomers will more than double Medicare and Medicaid costs by 2020. As health care costs increase faster than economic growth, Medicare taxes and the Trust Fund will cover less and less. By 2030, the Trust Fund will be bankrupt, and taxes will only pay for 48 percent of the costs. Federal health care costs are part of the mandatory budget. That means they must be paid. As a result, they are eating up funding for discretionary budget items, such as defense, education or the Justice Department.

OVERVIEW RESEARCH SWOT SOURCES

That’s one reason why Congress agreed to Obamacare. It required insurance companies to provide preventive care for free. It treated chronic conditions before they required expensive hospital emergency room treatments. It also reduced payments to Medicare Advantage insurers. Since 2010, when the Affordable Care Act was signed, health care costs rose by 4.3 percent a year. It achieved its goal of lowering the growth rate of health care spending. In 2010, the government forecasted that Medicare costs would rise 20 percent in just five years. That’s from $12,376 per beneficiary in 2014 to $14,913 by 2019. Instead, analysts were shocked to find out spending had dropped by $1,000 per person, to $11,328 by 2014. It happened due to four specific reasons: 1. The ACA reduced payments to Medicare Advantage providers. The providers’ costs for administering Parts A and B were rising much faster than the government’s costs. The providers’ couldn’t justify the higher prices. Instead, it appeared as though they were overcharging the government. 2. Medicare began rolling out accountable care organizations, bundled payments and value-based payments. Spending on hospital care has stayed the same since 2011. Part of the reason for this is that hospital readmissions dropped by 150,000 a year in 2012 and 2013. That’s one of the areas hospitals get penalized if they exceed standards. It resulted in increased efficiency and quality of patient care. 3. High-income earners paid more in Medicare payroll taxes and Part B and D premiums. It meant that the Medicare Part B premium charged to everyone else could remain at its current rate of $104.90 per month. For more, see Obamacare Taxes. 4. In 2013, sequestration lowered Medicare payments by 2 percent to providers and plans. Based on these new trends, Medicare spending was projected to grow just 5.3 percent a year between 2014 and 2024.

1960 Recession

1961 Recession Ends

1962

US SPENDING Percent Growth Cost Per Person

27.2 Billion NA $146

1963 US SPENDING Percent Growth Cost Per Person

32.6 Billion 8.6% $178

1965 Medicaid

US SPENDING Percent Growth Cost Per Person

1967

US SPENDING Percent Growth Cost Per Person

1969 US SPENDING Percent Growth Cost Per Person

65.9 Billion 12.9% $318

31.8 Billion 9.3% $166

1964 Medicare

1966 Vietnam War 46.1 Billion 10.1% $228

29.1 Billion 7.1% $154

38.4 Billion 11% $194

41.9 Billion 9% $209

1968 51.6 Billion 11.9% $253

US SPENDING Percent Growth Cost Per Person

58.4 Billion 13.3% $284

1970 Recession

1971 Wage Price Control

US SPENDING Percent Growth Cost Per Person

74.6 Billion 13.1% $355

82.7 Billion 11% $389

1972 Stagflation

1973 HMO Act

1974 ERISA

US SPENDING Percent Growth Cost Per Person

92.7 Billion 12% $431

102.8 Billion 11% $474

116.5 Billion 13.4% $534

1978 Inflation 9.0%

1979 Inflation 13.3%

1980 Inflation 12.5%

US SPENDING Percent Growth Cost Per Person

195.3 Billion 12.4% $865

1984 Tax Hike

1985

US SPENDING Percent Growth Cost Per Person

405 Billion 10.1% $1,692

221.5 Billion 13.4% $971

1986 Tax Cut 442.9 Billion 9.4% $1,833

US SPENDING Percent Growth Cost Per Person

1990 Recession

1991 Recession

1992

US SPENDING Percent Growth Cost Per Person

721.4 Billion 11.9% $2,843

255.3 Billion 15.3% $1,108

788.1 Billion 9.2% $3,070

474.7 Billion 7.2% $1,947

854.1 Billion 8.4% $3,287

1975 Inflation 6.9%

1976 Inflation 4.9%

1977 Inflation 6.7%

US SPENDING Percent Growth Cost Per Person

133.3 Billion 14.4% $605

152.7 Billion 14.6% $688

173.9 Billion 13.8% $777

1981 Fed Raises Rate

1982 Recession Ends

1983 Tax Hike

US SPENDING Percent Growth Cost Per Person

296.2 Billion 16% $1,273

334 Billion 12.8% $1,422

367.8 Billion 10.1% $1,550

1987 Black Monday

1988 Fed Raises Rate

1989 S&L Crisis

US SPENDING Percent Growth Cost Per Person

516.5 Billion 8.8% $2,099

1993 HMOs

1994

US SPENDING Percent Growth Cost Per Person

916.6 Billion 7.3% $3,487

579.3 Billion 12.2% $2,332

644.8 Billion 11.3% $2,571

1995 Fed Raises Rate 967.2 Billion 5.5% $3,641

US SPENDING Percent Growth Cost Per Person

1,021.6 Billion 5.6% $3,806

1996 Welfare Reform

1997 Balanced Budget Act

1998 LTCM Crisis

US SPENDING Percent Growth Cost Per Person

1,074.4 Billion 5.2% $3,964

1,135.5 Billion 5.7% $4,147

2002 War on Terror

2003 Medicare Modern Act

2004

US SPENDING Percent Growth Cost Per Person

1,629.2 Billion 9.6% $5,668

2008 Slowed Spending

2009

US SPENDING Percent Growth Cost Per Person

2,399.1 Billion 4.5% $7,897

2014 Exchanges Opened

2015

US SPENDING Percent Growth Cost Per Person

3,029.3 Billion 5.3% $9,515

1,768.2 Billion 8.5% $6,098

1,202 Billion 5.8% $4,345

1,896.3 Billion 7.2% $6,481

2010 ACA Signed 2,494.7 Billion 4% $8,141

3,205.6 Billion 5.8% $9,990

US SPENDING Percent Growth Cost Per Person

2,596.4 Billion 4.1% $8,404

1999 BBRA

2000 BIPA

US SPENDING Percent Growth Cost Per Person

1,278.3 Billion 6.4% $4,576

2005 Bankruptcy Act

2006

US SPENDING Percent Growth Cost Per Person

2,024.2 Billion 6.7% $6,855

2001 9/11 1,369.7 Billion 7.1% $4,857

US SPENDING Percent Growth Cost Per Person

1,486.8 Billion 8.5% $5,220

2007 2,156.5 Billion 6.5% $7,233

US SPENDING Percent Growth Cost Per Person

2,295.7 Billion 6.5% $7,628

2011 Debt Crisis

2012 Fiscal Cliff

2013 ACA Taxes

US SPENDING Percent Growth Cost Per Person

2,687.9 Billion 3.5% $8,638

2,795.4 Billion 4% $8,915

2,877.6 Billion 2.9% $9,110

+ TOTAL US SPENDING TOTAL GROWTH + 3178.4 Billion Total Percent Growth + 11,685% Total Cost Per Person Growth + $9,844

EXPENSES WHY THE US IS THE ONLY RICH COUNTRY WITHOUT UNIVERSAL HEALTH CARE Annalisa Merelli 4/18/2017

SUMMATION + Wayne county is would be affected the most is the ACA was repealed. There’s been debate about repealing or reforming the ACA but no solutions have been made yet.

OVERVIEW RESEARCH SWOT SOURCES

For now, at least, the health-care fight in the US is over. The Senate bill replacing president Barack Obama’s Affordable Care Act has collapsed after two more Republican senators withdrew their support, leaving the ruling party without a majority. Senate majority leader Mitch McConnell is proposing to repeal Obamacare entirely, with a two-year delay so his party can negotiate a new bill, but several Republicans oppose that too. That leaves the US with Obamacare, whose signal achievement was to cut by 20 million (pdf) the number of Americans without health insurance; the Republican plan would have entirely reversed those gains. But Obamacare still leaves nearly 30 million people not covered and, as Republicans complain, burdens middle-class Americans with higher insurance premiums and the government with higher subsidies. So why does the US, the only industrialized nation without universal health coverage, also have not only the highest health-care spending in the world—both in absolute terms and as a share of GDP—but also one of the highest levels of government spending on health care per person? And how did it come to be this way? The answer is that the lack of universal coverage and high costs are intimately linked—both economically and historically. Single-payer health-care (in which the government pays for universal coverage, typically through taxes) helps keep costs down for two reasons: It means that the government can regulate and negotiate the price of drugs and medical services, and it eliminates the need for a vast private health-insurance bureaucracy. Currently, the US spends two to three times as much per capita on health care as most industrialized countries. Of this burden, an estimated two thirds falls on the government’s shoulders, when one accounts for entitlements (Medicare and Medicaid), the cost of health insurance for government workers, and tax credits that

EXPENSES

OVERVIEW RESEARCH SWOT SOURCES

subsidize private insurance plans for other people. “Most Americans have publicly funded health care,” either in full or in part, says David Himmelstein, professor of public health at CUNY and author of the estimate. “The government spends much more than other countries, but it’s an opaque system.” The government’s role is mostly to subsidize the astronomical costs set by the for-profit market. Many Americans think their system is expensive because it’s very good. They are wrong: The US ranks 28th, below all other rich countries, when it comes to the quality of its healthcare assessed by UN parameters.

CAMPAIGNS, INC.

BUT HOW DID AMERICA GET HERE?

Lepore explains that their slogan, “political medicine is bad medicine,” was used to lobby newspapers (with which they had advertising relations) and the population against government intervention in matters of health. They reminded people that what they called “socialized medicine” was a German invention—it came from the same country American soldiers were fighting abroad.

When did the country diverge from other industrialized nations and, rather than offering universal health coverage, built up a system that relied on private insurance? It wasn’t one moment, says Karen Palmer, professor of health science at Simon Fraser University, but rather, “a series of decisions, turning points, and cascading events.” Though until World War I there had been some attempts by socially liberal governments to follow the examples of Germany and others, they were met with opposition from doctors, insurance companies, businesses, and even some conservative labor organizations, which considered state-sponsored health care paternalistic and unnecessary. Labor unions also worried that it would weaken their own bargaining power, says Palmer, as they were otherwise responsible for getting their members social services. But the root of the current system, Palmer says, can be found in World War II. In 1943 president Franklin D. Roosevelt imposed an effective freeze on labor wages, and companies started offering health and pension benefits as a way to retain workers instead. This was the beginning of employer-sponsored healthcare, though there was no government mandate to offer it (except in Hawaii). Unions began negotiating the benefits as part of what they could obtain for workers. The rest of the population wasn’t covered, but it meant the unions didn’t put pressure on the government to create a public health system.

Another turning point, Palmer says, was an exceptionally successful campaign by Clem Whitaker and Leone Baxter, the founders of Campaigns, Inc.—”the first political consulting firm in the history of the world,” as The New Yorker’s Jill Lepore described it (paywall). On behalf of the California Medical Association, the two opposed California governor Earl Warren’s 1944 plan to introduce compulsory health insurance in the state, paid for through Social Security.

According to Lepore, after successfully halting the reform in California, Campaigns, Inc. used a similar strategy—this time on behalf of the American Medical Association—to block president Truman’s 1949 proposal of a public health plan. Their campaign, which included riding anti-communist sentiment to terrorize people against the specter of “socialized medicine” and “convincing the people […] of the superior advantages of private medicine, as practiced in America, over the State-dominated medical systems of other countries” successfully turned popular support against Truman. This rejection of universal health coverage as a form of “collectivization” or “bolshevization,” says Theodore Brown, professor of public health and policy at the University of Rochester, had begun several decades before. In the 1910s, right-wing politicians, medical professionals, and representatives of the medical industry opposed attempts to broaden national health coverage on the grounds that it was a Soviet-inspired concept—an objection that gained force after the Russian revolution.

That sentiment, Brown believes, is still alive. Despite knowing well that a single-payer healthcare system is the only sustainable long-term solution for creating broader coverage without skyrocketing prices, he says, even advocates of single-payer like Nobel Prize-winning economist Paul Krugman consider it politically unfeasible. The result is that American doctors and the medical industry benefit from a system that pays them significantly more than doctors elsewhere—although, taking into account the cost of medical studies in the US, their standard of living isn’t necessarily that much higher. Contrast this with Britain, which in 1948, as the country was patching itself up from World War II, introduced the National Health Service (NHS). The reform was proposed during the war, and was based on the principle that health care for salaried workers and their dependents needed to be provided by the state, as it wasn’t coming from businesses. This request, led by the Labour party, found an ally in the UK’s need to guarantee the survival of voluntary hospitals that had been opened during the war and risked failing without government support. NO LABOR, NO PARTY Throughout, however, “if there is one overarching explanation” for why the US doesn’t have universal health care, “it is that there hasn’t been a labor party in the US that represents the working class,” Himmelstein says. Palmer agrees: “It is the core value of the labor party to bring social solidarity.” The Democratic party has ties with unions and includes those who believe in European-style welfare policies. But it always had a strong pro-business soul which prevented it from focusing primarily on the needs of the working class. One reason no true labor party has emerged is that no large portion of US society considers itself “working class.” As Bruce Vladeck, a researcher with Mount Sinai Medical Center, noted in a 2003 paper in the American Journal of Public Health, “in the United States, everyone selfidentifies as middle class.”

Therefore, the labor movement isn’t large enough to demand welfare reforms such as universal health coverage. Further, Brown says, the labor movement is fragmented, containing a range of views on both healthcare and on other issues. The wide-scale demonization of socialist ideas took place within the labor movement, too, which progressively moved toward the center. Even in the progressive eras of presidents Kennedy and Carter, while there were some attempts to pass universal health care, none was successful. They were blocked by the American middle class’s association of public programs with charity, as well the by-then powerful insurance and medical lobbies dedicated to opposing not-for-profit care. Inequality and segregation have also played a role. The lack of universal health-care coverage tends to be hardest on racial minorities who, being more likely to be poor, are more likely to be on welfare. The Atlantic’s Vann Newkirk notes that the the battle for black civil rights and access to health care have historically been close; the introduction in 1965 of Medicare and Medicaid (government insurance for the poor and the elderly, respectively) struck a powerful blow against segregation, since it channeled federal funds to hospitals and thus, under the Civil Rights Act passed a year earlier, banned them from discriminating on the grounds of race. However, African Americans are still the most likely to be uninsured. According to the Kaiser Family Foundation, as of 2015, 12% of the black population and 17% of Hispanics were uninsured, compared to 8% of whites.

EXPENSES PAYING MORE FOR LESS Despite the evidence that a single-payer system would be a more efficient and cheaper choice, introducing it in the US is not a serious option. Trying to dismantle the current system would be a mammoth task. For one thing, it would cost a great many jobs: Health- and lifeinsurance companies employ some 800,000 people, with yet more employed by the medical industry just to deal with insurance companies. Though the savings from eliminating them could be invested in retraining those people for other professions, it would be difficult for any party to convince voters that it’s a necessary step. And with a market worth more than $3 trillion, drug firms, medical providers, and health technology companies have an incentive to maintain a system that lets them set prices instead of negotiating with a single government payer. Both the GOP and the Democratic party are under the influence of the medical-industrial complex: In 2016, hospitals and nursing homes contributed over $95 million to electoral campaigns in the US, and the pharmaceutical sector gave nearly $250 million. WHAT ABOUT BERNIE THOUGH The popularity of Bernie Sanders and his single-payer health care model during the 2016 Democratic primaries, however, is a signal that more Americans are open to the idea. Certainly more than in 1993, when Hillary Clinton, then first lady, was heavily criticized for her attempt to push a universal coverage plan. Gallup’s polls suggest that after a few years of skepticism Americans are again warming up to the idea that health care should be a government responsibility. But the power of anti-socialist rhetoric is such that people’s views vary a great deal depending on how the question is asked, Palmer points out. When asked (in April 2017) by YouGov whether they’d want to expand “Medicare for all” (pdf), 60% answered positively; when asked (in June 2017) about introducing “single-payer” health care (pdf), only 44% agreed.

OVERVIEW RESEARCH SWOT SOURCES

The two questions are “essentially the same from a policy perspective,” commented Don McCanne, senior fellow at Physicians for a National Health Program. “But the layman hears the first question as being the expansion of Medicare to cover everyone… whereas the second question is about single payer, government, and taxes.” The Republicans’ failure to pass their health-care law seems to confirm a prediction made early in the Trump administration: that once people had had a taste of increased health-care security with Obamacare, they wouldn’t easily forget it. “One of the unintended consequences of [the Republican reform],”says Palmer, “is that people are feeling more threatened.” But universal care? That’s still a big leap.

MENTAL

OVERVIEW RESEARCH SWOT SOURCES

MENTAL DISORDERS IN AMERICA John A. Daller, MD 6/22/2017

SUMMATION + Different types of mental illnesses in American along with broad statistics about each illness. Includes depression, suicide, anxiety ADHD, eating disorders, autism, Alzheimerâ&#x20AC;&#x2122;s, and schizophrenia.

MENTAL DISORDERS IN AMERICA Mental disorders are common in the United States and internationally. In 2015, there was an estimated Americans adults with a diagnosable mental disorder. This is an estimate of 43.4 million people. In addition, 4 of the 10 leading causes of disability in the U.S. and other developed countries are mental disorders major depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder. Many people suffer from more than one mental disorder at a given time. In the U.S., mental disorders are diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). DEPRESSIVE DISORDERS Depressive disorders encompass major depressive disorder, dysthymic disorder, and bipolar disorder. Bipolar disorder is included because people with this illness have depressive episodes as well as manic episodes. In 2015, approximately 16.1 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year, had a depressive episode in the past year. Nearly twice as many women (8.5

percent) as men (4.7 percent) are affected by a depressive disorder each year. Depressive disorders may be appearing earlier in life in people born in recent decades compared to the past. Depressive disorders often co-occur with anxiety disorders and substance abuse. SUICIDE In 2015, more than 44,000 people died from suicide in the U.S. More than 90 percent of people who kill themselves have a diagnosable mental disorder, commonly a depressive disorder or a substance abuse disorder. The highest suicide rates in the U.S. are found in men over age 75. The suicide rate in young people increased dramatically over the last few decades. In 2015, suicide was the 2nd leading cause of death among 15 to 24 year olds. Four times as many men than women commit suicide; however, women attempt suicide 2-3 times as often. ANXIETY DISORDERS Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and

phobias (social phobia, agoraphobia, and specific phobia). Approximately 33.1 percent of adults in the U.S. have an anxiety disorder. Anxiety disorders frequently co-occur with depressive disorders, eating disorders, or substance abuse. Many people have more than one anxiety disorder. Women are more likely than men to have an anxiety disorder. Approximately twice as many women as men suffer from panic disorder, posttraumatic stress disorder, generalized anxiety disorder, agoraphobia, and specific phobia, though about equal numbers of women and men have obsessive-compulsive disorder and social phobia. ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) ADHD, one of the most common mental disorders in children and adolescents, affects an estimated lifetime prevalence of 9.0% of 13 to 18 year olds. About 2-3 times more boys than girls are affected. ADHD usually becomes evident in preschool or early elementary years. The disorder frequently persists into adolescence and occasionally into adulthood.

EATING DISORDERS The 3 main types of eating disorders are anorexia nervosa, bulimia nervosa, and binge-eating disorder. Females are much more likely than males to develop an eating disorder. Only an estimated 0.1% to 0.3% of the population will be male with anorexia or bulimia and an estimated 2 percent of the population with binge-eating disorder are male. In their lifetime, an estimated 0.9% of females suffer from anorexia and an 0.5% suffer from bulimia. Community surveys have estimated that 1.2% of Americans experience binge eating disorder. AUTISM Autism affects an estimated 1 in every 68 eight-year old children. Autism and related disorders (also called autism spectrum disorders or pervasive developmental disorders) develop in childhood and generally are apparent by age 3. Autism is about 4 times more common in boys than girls. Girls with the disorder, however, tend to have more severe symptoms and greater cognitive impairment. 2/3

ALZHEIMER’S DISEASE Alzheimer’s disease, the most common cause of dementia among people age 65 and older, affects an estimated 4 million Americans. As more and more Americans live longer, the number affected by Alzheimer’s disease will continue to grow unless a cure or effective prevention is discovered. The duration of illness, from onset of symptoms to death, averages 8 - 10 years. SCHIZOPHRENIA Approximately 1.1 % of the population age 18 and older have schizophrenia. 1/3 Schizophrenia affects men and women. Schizophrenia often first appears earlier in men, usually in their late teens or early 20s, than in women, who are generally affected in their 20s or early 30s.

MENTAL ERODING FUNDING THREATENS MENTAL HEALTH SERVICES IN WEST MICHIGAN Mark Tower 1/29/2018

SUMMATION + In western Michigan mental health funding is threatening health services. Budget and labor is being cut, enrollment is down, stored funding has flat lined along with revenue.

OVERVIEW RESEARCH SWOT SOURCES

GRAND RAPIDS, MI Mental health services are being scaled back in West Michigan as a regional board grapples with a multimilliondollar budget deficit. Though there are disagreements on both the cause and scale of the problem, most agree a statewide revenue shift has occurred that could affect services for some of Michigan’s most vulnerable residents. Network 180, Kent County’s community mental health authority, recently eliminated 17 employees, froze hiring for another 15 positions and cut another $778,000 in services. That only solved a small portion of the more than $10 million problem Network 180 faces in its 2016-17 fiscal year, the local share of a $21-$23 million shortfall estimated at the regional level. Kent County cuts mental health services in face of $10M shortfall Though it manifested locally, the root problem threatens both providers and recipients of mental health services statewide, Network 180 Executive Director Scott Gilman recently told a packed room of concerned citizens. “In many ways we’re the canary in the coal mine,” Gilman said. Network 180 coordinates a variety of services available to those in the community with mental illnesses, developmental disabilities and substance-abuse disorders. It is one such local mental health system within Lakeshore Regional Entity, which coordinates community mental health services across a seven county region. A $23 million shortfall represents about 8 percent of the region’s total budget, and is expected to all but drain the entity’s cash reserves. With all of the $11 million in its internal service fund committed to covering the large, unexpected shortfall in the 2017 fiscal year, Lakeshore Regional Entity CEO Jeffrey Brown said the region is looking toward 2018 and asking each community to bear its share of the burden. “We have only so much money,” Brown said. “We can get through ‘17. But are we going to have enough for ‘18? That’s the question.”

THE ‘DAB’ PROBLEM The region started tracking lagging revenue in one of its funding sources early in 2017, noting a spike in the number of patients leaving traditional Medicaid, particularly those who qualify for federal assistance as disabled, aged or blind - known commonly as “DAB” clients. “The last seven years in DAB enrollments, it’s been flat,” Lakeshore Regional Entity Chief Financial Officer Jeff Labun said. “Then all of a sudden last year, at end of 2016, it started dropping like crazy.” Robert Sheehan is CEO of the Community Mental Health Association of Michigan, the advocacy organization representing local community mental health programs across the state. The number of DAB enrollments “fell off a cliff” in 2016 and 2017, Sheehan said, as a simpler and quicker process and more advantageous benefits drew patients instead to the Healthy Michigan Plan, the state’s Medicaid expansion under the Affordable Care Act. “Which is a good thing for clients, but terrible for revenues,” he said. For example, Sheehan said a client does not need to prove any disability if they enroll in the Healthy Michigan Plan. Less paperwork, shorter waits and, in some cases, less requirements that patients pay for services out of pocket are all reasons it might be better for patients than the old system, he said. But the dropping enrollment numbers also means dipping reimbursements to mental health authorities like Network 180. It’s what prompted Kent County to make the cuts to staffing and services, which are expected to reduce expenses by about $2.8 million. One Kent County commissioner compared the decision to a trapped mountain climber cutting off an arm to free himself. “This is incredibly, incredibly painful to me,” said Jim Talen, a Network 180 board member, during the Jan. 8 meeting. Grand Rapids clubhouse spared amid ‘painful’ cuts to mental health With its share of the regional shortfall exceeding $10 million, Gilman pointed

out the board still has a long way to go. And there is the possibility that a continued loss of DAB enrollees might only make budget shortfalls worse in the current 2017-18 fiscal year. “I’m still seeing it in ‘18,” Labun said. “The DABs haven’t rebounded. They’re still going down.” As local officials scramble to address the problem, the state government contests the scale of 2017 fiscal year losses reported by the region and by Sheehan’s association. An analysis from financial services firm Rehmann - solicited by the Community Mental Health Association of Michigan - concluded movement of Medicaid recipients away from DAB in 2016 and 2017 amounted to a $97 million statewide impact. Lakeshore Regional Entity alone stood to lose $10.8 million over the two years, according to the analysis. A slide from a report by the Community Mental Health Association of Michigan shows recent decline in enrollment for disabled, aged and blind (DAB) Medicaid recipients. Courtesy | CMHA of Michigan Many DABeligible clients, the analysis found, moved to one of two other programs - either Temporary Assistance for Needy Families (TANF) or the Healthy Michigan Plan - both of which have much lower reimbursement rates. At the current rates, Sheehan said, Medicaid reimburses about seven times more for DAB enrollees than for Health Michigan enrollees and about 16 times more than for TANF enrollees. Because of that dramatic difference, the financial effect of a small drop in DAB enrollees can quickly be compounded, he said. One caveat - the Rehmann analysis makes assumptions for the effect in Macomb County, the only of the prepaid inpatient health plans not to participate. A separate analysis not including estimated Macomb County numbers concluded there was a nearly $90 million loss across the nine other regions.

MENTAL

OVERVIEW RESEARCH SWOT SOURCES

STATE OFFICIALS DISAGREE Lynda Zeller, director of the Behavioral Health and Developmental Disabilities Administration within the Michigan Department of Health and Human Services, confirmed the state government has noticed a decrease in what has been paid out to prepaid inpatient health plans like Lakeshore Regional Entity. Zeller said she was unable to give alternate budget figures until the 2017 fiscal year is finalized, but said the state’s data does not suggest anywhere near the $97 million problem identified in the Rehmann analysis. “Nothing like the numbers they’re talking about,” she said. “Our numbers absolutely do not agree with the independent assessment that was done by the CMH association, or what they’re calling an independent assessment.” The state government has its own analysis looking at the changes in DAB enrollment numbers. Between October 2015 and February 2017, the state charted a net loss of about 3.6 percent of DAB enrollees 18,763 over that 17-month period. Though DAB enrollments have declined, this slide from a Community Mental Health Association of Michigan report shows overall Medicaid enrollments have increased. Courtesy | CMHA of Michigan By comparison, Community Mental Health Association of Michigan claims a much larger number of DAB-eligible Michiganders were “erroneously classified” as either Healthy Michigan Plan or Temporary Assistance for Needy Families participants - 27,008 in 2016 and 41,775 in 2017. Though their numbers differ, Zeller confirmed there has been change. “There is no disagreement that they’ve experienced some sort of less revenue against projections,” she said. “However, that is not unusual. That happens every year.” It’s why a healthy reserve fund needs to be maintained, Zeller said. Sheehan agreed that movement between Medicaid classifications is normal, but says the scale of the shift seen since 2016 caught everyone by surprise. “No one saw this transfer coming,” he said.

If the current reimbursement rates don’t change, Sheehan said, the resulting losses could quickly eat away at reserve funds and threaten the system as a whole. “Once you’re bankrupt, you can’t get back on your feet,” he said. ‘BETWEEN A ROCK AND A HARD PLACE’ Lakeshore Regional Entity is no stranger to its allocations not matching initial predictions or even actual expenditures in a given year. Past financial audits often show shortfalls in the millions in one or more of the region’s key funding sources. But never close to the estimated $23 million loss being estimated for the 201617 fiscal year. Brown and Labun do not see the recent changes as routine fluctuations, but a significant shift in revenue that threatens to drain all available cash reserves within a matter of months. The region notified the state in January and, as the decline continued into the year, held a meeting in July to outline the problem, Brown said. Initially, they were hoping a rate adjustment might be enacted to soften the blow of the lost revenue. But after the fiscal year ended, Brown said, the state’s actuarial firm notified the region there would be no such adjustment. “That’s when it turned,” he said. “The fact that nothing happened puts us squarely between a rock and a hard place.” The reason no change was made, Zeller said, is because they looked at the situation mid-year in 2017 and the current rates remained “actuarially sound.” The review process is continuous, she said, and will ultimately correct any shifts in enrollment. That could be immediate, if a problem with the current rates is identified, or could happen as a result of the normal annual readjustment process. “When there’s reason to believe the rates are no longer actuarially sound, we can move at any time,” Zeller said. One thing Lakeshore Regional Entity and Network 180 should not do, she said, is cut any of the mandated services for Medicaid

recipients. “It is not acceptable for a PIHP or its member CMHs to eliminate or reduce services due to budget,” Zeller said. “They must provide all medically necessary services to people. The state shares in the risk and, ultimately, is at risk for those costs.” Similar advice from the state caused Network 180 to remove from its list of cuts a program that provides a supportive community and a variety of services to local Medicaid recipients with mental illness. Members celebrate ‘second chance’ for mental health clubhouse Sheldon House, Kent County’s program affiliated through Clubhouse International, nearly closed its doors this year after 28 years in the community. But Network 180 ultimately resolved to remove the program from its list of cuts, at a cost of about $410,000. DWINDLING RESERVES Lakeshore Regional Entity was formed in 2014 when Michigan’s 18 prepaid inpatient health plans were consolidated into 10. They are primarily multi-county networks, with the exception of Oakland, Macomb and Wayne counties. Lakeshore Regional Entity is responsible for management of Medicaid benefits in Allegan, Kent, Lake, Mason, Muskegon, Oceana and Ottawa counties. At the time of its formation, the region held reserves of $11.3 million in an internal service fund and another $8.2 million of Medicaid savings, both of which were brought into the region by the merging entities. The amounts in the region’s reserves have not changed much since that time, Labun said. “It’s been flat for the last three or four years,” he said. Given the size of the population it serves, Lakeshore Regional Entity already had one of the smallest pools of risk reserves in the state, Sheehan said. That’s why the problem tied to DAB enrollments manifested there first. “We see the LRE

problem as sort of the tip of the spear,” he said. The region ended the 2015-16 fiscal year with internal service fund reserves of just over $11 million, about $4.4 million in reserves for the Healthy Michigan program and another about $6.9 million in savings from the state’s tax on liquor sales, intended for use on substance abuse prevention and treatment - for total reserves of about $22 million. Though the state’s third most populous region, Brown said, only one other had less in its risk reserve fund at the start of the 2017 fiscal year. “We were already in a vulnerable state,” he said. Statewide, community mental health risk reserves haven fallen from roughly 6 percent of total budgets in 2015 to 4.5 percent in 2017, Sheehan said. “They’re eroding pretty rapidly,” he said. It’s difficult for the local community mental health authorities to build reserves, Sheehan said, without the funds to do so built into their Medicaid reimbursement rates. If the current trend continues and Medicaid reimbursement rates are not adjusted quickly, he said, other regions will likely run dry by 2019. Though Lakeshore Regional Entity expects most of its reserves will be drained to cover the 2017 shortfall, exactly how much might be left will not be known until final audits are completed on the 2016-17 fiscal year, which closed Sept. 30. “The numbers aren’t finalized yet,” Labun said. “Our last projection in November was $23 million. It could go down. Hopefully it won’t go up. ”Initially, those final numbers were expected at the end of February, Zeller said, but state officials are now asking for them by the end of January. The state shares a portion of the risk whenever shortfalls occur - covering half the total of any shortfalls over 5 percent of annual spending and the entirety of any shortfalls over 10 percent. Assuming a $23 million loss, Labun said, Lakeshore Regional Entity will be responsible for $17.75 million,

MENTAL with the state covering the remaining $5.25 million. That would drain all but about $4.25 million of liquor tax funds, which would be the only remaining reserves to cover any shortfall seen in the current fiscal year, already in its second quarter. A ‘REVENUE PROBLEM?’ All the more reason for Lakeshore Regional Entity and its members to work collaboratively on both revenue and expense-based solutions, Brown said. “You can’t divorce the two,” he said. Brown said there are opportunities to improve how the region predicts and controls its expenditures. “That’s what the state is coming back and communicating to us,” he said. “How do you provide services in times of reduced revenue? That’s our task. No one likes it, because our needs sure haven’t gone away, but that’s our charge.” Zeller says a history of fiscal irresponsibility and mismanagement is one reason why the region finds itself in its current predicament. Annual financial audits show a net surplus of $3.4 million in 2016, but charted losses in the first two years of the Lakeshore Regional Entity’s existence - $3.6 million in 2015 and $7.7 million in 2014. Zeller points to a corrective action plan the state required of the region late in 2015. A state audit identified problems with the region’s care functions, risk management strategy and conflicts of interest. According to a December 2015 letter from Bureau of Community Based Services Director Thomas Renwick, those issues “raise legitimate concerns” about the region’s ability to fulfill the requirements of its contract with the state. “That’s the unique part about this region,” Zeller said. She said the state remains concerned about duplication seen in non-service functions from one community mental health authority to another as well as the duplication of services handled by both the individual authorities and the regional office.

OVERVIEW RESEARCH SWOT SOURCES

“We believed the managed care functions of this PIHP were inefficient,” Zeller said. “There was a lot of what we call horizontal and vertical duplication.” The goal for Lakeshore Regional Entity needs to be to eliminate any such duplication of services, she said. “What the state wants is to see is the duplicity and non-service functions minimized and eliminated such that a greater percentage of the state’s fiscal investment gets to direct services,” Sheehan contests any claim that the problem lies with administrative costs or with duplication of services. “The entire LRE budget is $6 million,” he said. “The problem in the LRE region is $23 million. Administration is the smallest piece of this. “It’s really a revenue problem.” The Lakeshore Regional Entity staff expanded from 15 to 31 during the 2015-16 fiscal year, according to internal audit documents, and administrative expenses totaled $3.6 million. Any duplication that exist - where individual community mental health authorities still handle managed care functions that the state is asking them to regionalize - is in response to movements at the state level toward eliminating or privatizing the regional prepaid inpatient health plans, Sheehan said. “It’s hard for a CMH to give all managed care functions to PIHP when state continues to threaten the existence of PIHPs,” he said. Though he understands the temptation to focus on the revenue losses and place blame on state officials, Brown said the situation is much more complicated. “No doubt, there’s a portion of that we’re all going to have to answer together,” he said. “But at the end of the day also there’s some significant pieces about our expenses and how we work as a region that have to be addressed.” In the meantime, Lakeshore Regional Entity’s Board of Directors in December decided to explore the possibility of bidding out the organization’s managed care functions and to seek bids for a potential emergency financial management.

Kent County Commissioner Stan Stek, who sits on the Lakeshore Regional Entity board, updated his fellow county leaders on the situation Thursday, Jan. 25. “That’s a radical change and shift in how this thing is going to function,” Stek said. Amid that uncertainty, Brown said the region is committed to finding a solution, and will continue to look at both sides of its ledger sheet. “We’ve got to get there,” he said. “We’ve got to find our way.”

MENTAL

OVERVIEW RESEARCH SWOT SOURCES

WAYNE COUNTY HAS WORST HEALTH OUTCOMES IN MICH. James David Dickson 3/16/2016

SUMMATION + Wayne County is ranked last in health outcomes due to weaker family structure, poor mental health, violent crimes, and has greater quality of life issues than the state as a whole.

Wayne County, Michigan’s most populous county, ranks last in health outcomes, according to the 2016 County Health Rankings published this week by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. The numbers reveal that by many measures, Wayne County has weaker family structure, poorer mental health, more violent crime, and more qualityof-life problems than its neighbors or the state as a whole. Future reports will explain what public officials are doing about it. For now, here are some of the highlights of where things stand. MENTAL HEALTH WOES, VIOLENT CRIME TROUBLE WAYNE COUNTY Adults in Wayne County reported an average of 4.1 mentally unhealthy days per month. The state average, 3.7 days per 30, is almost a full day higher than the number for the top 10 percentile for Americans, 2.8 days per 30. This means Wayne County residents spend about a full day and a third more of each month in a mentally unhealthy state, relative people in the happiest counties nationwide. This accounts for 10 percent of the weight of the health outcomes score.

On violent crime, which accounts for 2.5 percent of health factors, Wayne County, with 1,089 violent crimes per 100,000 residents, is out of whack with both Metro Detroit and the state as a whole. Statewide, the average is less than half that of Wayne County, or 464 per 100,000; in Oakland County, it’s 223; in Washtenaw County, 317; and in Macomb, 303. The top 10 percentile nationwide is 59. This means Wayne County has 18 times more violent crime than the safest counties in America. FAMILY MATTERS Just under half of all Wayne County children, 48 percent, live in singleparent homes, which accounts for 2.5 percent of the weight of health factors. The state average is 34 percent, more than one in three Michigan children. In Macomb County, it’s 29; in Oakland County, the number is 25 percent. In Washtenaw, 27 percent. The top 10 percentile nationwide is 21 percent. If family formation is unstable in Wayne County, the same can be said of housing. Almost one in four Wayne County residents, or 23 percent, deals with one of the following issues: overcrowding, high costs, lack of a kitchen or lack of plumbing facilities,

according to the study. Oakland, Macomb, Washtenaw and the state average are all between 16 and 18 percent. Severe housing problems account for 2 percent of health factors. Teen birth numbers reveal a wide gap between Metro Detroit counties and not only Wayne County, but the state as a whole. Defined as the number of births by girls 15-19, per 1,000, Wayne County has 43. The state average is 29. The top 10 percentile nationwide is 19, a number that Washtenaw (11), Oakland (16) and Macomb (19) counties either best or tie. This makes up 2.5 percent of the health factors score.

Macomb (93) and Washtenaw (92) also are within the top 10 percentile. Bad news here comes in two forms: access to exercise opportunities is only 1 percent of the health factors score. And high particulate levels in the air are a regionwide problem. Measured in milligrams per cubic meter, this accounts for 2.5 percent of the health factors score. Wayne County isn’t much worse off than its neighbors on air quality, but all do worse than the state average of 11.5. Wayne County’s 12.8 compares to Macomb and Washtenaw’s 12.7 and Oakland County’s 12.5. The top 10th percentile nationwide is 9.5.

GOOD NEWS AND BAD NEWS

GONE TOO SOON

There are measures where Wayne County leads the nation. Some 94 percent of county residents have adequate access to exercise opportunities, which is defined in three ways: in census block, a half mile or less from a park; for urban areas, being a mile or less from a recreation center; in rural areas, being 3 miles or less from a recreation center. This tops not only the state average of 84 percent, but the top 10 percentile nationwide, of 91 percent. Oakland (94 percent),

Wayne County residents die prematurely at a far greater rate than their neighbors — twice as much as people in Washtenaw County. Defined as years of potential life lost before age 75, and accounting for 50 percent of health factors, Wayne County residents lost 9,900 such years, based on 201113 data. This compares to 4,900 for Washtenaw County, 5,800 for Oakland County, 7,100 for Macomb County, and a state average of 7,200. The top 10th percentile nationwide was 5,200.

OTHER RANKINGS While Wayne County ranked 83 out of 83 in health outcomes, Washtenaw ranked seventh, Oakland ranked 15th, and Macomb 58th. As for health behaviors, such as smoking, obesity, and physical activity, among others, Oakland County ranked second and Washtenaw third. Macomb ranked 55th while Wayne County came in secondto-last at 82nd. For health factors, which include behaviors and access to medical care, socioeconomic factors, and the physical environment, Wayne County ranked dead last. Washtenaw ranked first, and Oakland fifth.

MENTAL

OVERVIEW RESEARCH SWOT SOURCES

HEALTH INSURERS ARE STILL SKIMPING ON MENTAL HEALTH COVERAGE Jenny Gold 11/30/2017

SUMMATION + With the Mental Health Parity and Addiction Equality Act mental health should be as accessible as going to the doctor. However studies show that most mental care is more likely provided out of network, has high costs for nonprofessional treatment, and vary from state to state.

It has been nearly a decade since Congress passed the Mental Health Parity And Addiction Equity Act, with its promise to make mental health and substance abuse treatment just as easy to get as care for any other condition. Yet today, amid an opioid epidemic and a spike in the suicide rate, patients are still struggling to get access to treatment. That is the conclusion of a national study published Thursday by Milliman, a risk management and health care consulting company. The report was released by a coalition of mental health and addiction advocacy organizations.

AMONG THE FINDINGS: • In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care. • Insurers paid primary care providers 20 percent more for the same types of care than they paid addiction and mental health care specialists, including psychiatrists. • State statistics vary widely. In New Jersey, 45 percent of office visits for behavioral health care were out-ofnetwork. In Washington, D.C., it was 63 percent. The researchers at Milliman examined two large national databases containing medical claim records from major insurers for PPOs — preferred provider organizations — covering nearly 42 million Americans in all 50 states and D.C. from 2013 to 2015. “I was surprised it was this bad. As someone who has worked on parity for 10-plus years, I thought we would have done better,” says Henry Harbin, former CEO of Magellan Health, a managed behavioral health care company.

MENTAL “This is a wake-up call for employers, regulators and the plans themselves,” Harbin says, “that whatever they’re doing, they’re making it difficult for consumers to get treatment for all these illnesses. They’re failing miserably.” The high proportion of out-of-network behavioral care means patients with mental health or substance abuse problems were far more likely to face the high out-ofpocket costs that can make treatment unaffordable, even for those with insurance. In its statement issued with the report, the coalition of mental health advocacy groups, which included Mental Health America, the National Association on Mental Illness and The Kennedy Forum, called on federal regulators, state agencies and employers to conduct random audits of insurers to make sure they are in compliance with the parity law. Harbin, now a consultant on parity issues, said the report’s finding that mental health providers are paid less than primary care providers is a particular surprise. In nine states, including New Hampshire, Minnesota, Vermont, Maine and Massachusetts, payments were 50 percent higher

for primary care providers when they provided mental health care. Because of low reimbursement rates, Harbin said, professionals in the mental health and substance abuse fields are not willing to contract with insurers. The result is insurance plans with narrow behavioral health networks that do not include enough therapists and other caregivers to meet patient demand. For years, insurers have maintained that they are making every effort to comply with the 2008 federal mental health parity law, which was intended to equalize coverage of mental health and other medical conditions. And previous research has found that they have gone a long way toward eliminating obvious discrepancies in coverage. Most insurers, for example, have dropped annual limits on the number of therapy visits that they will cover. Higher co-payments and separate deductibles for mental health treatment have become less of a problem. Still, discrepancies appear to continue in the more subtle ways that insurers deliver benefits, including the size of provider networks.

OVERVIEW RESEARCH SWOT SOURCES

Kate Berry, a senior vice president at America’s Health Insurance Plans, the industry’s main trade group, says the real problem is the shortage of behavioral health clinicians. Health plans are working very hard to actively recruit providers and offer telemedicine visits in areas with shortages, says Berry. “But some behavioral health specialists opt not to participate in contracts with providers, simply because they prefer to see patients who are able to pay out of their pocket and may not have the kind of severe needs that other patients have.” “This is a challenge that no single stakeholder in the health care infrastructure can solve,” she adds. Carol McDaid, who runs the Parity Implementation Coalition, counters that insurers have been willing and able to solve provider shortages in other fields. When, for example, there was a shortage of gerontologists, McDaid says, insurers simply increased the rates and more doctors joined the networks. “The plans have the capacity to do this,” she says. “I just think the will hasn’t been there thus far.”

The scarcity of therapists who accept insurance creates a care landscape that is difficult to navigate for some of the most vulnerable patients. Ali Carlin, 28, says she used to see her therapist in Richmond, Va., every week, and had a co-payment of $25 per session. But in 2015, the therapist stopped accepting her insurance and her rate jumped to $110 per session. Carlin, who has both borderline personality disorder and addiction problems, says she called around to about 10 other providers, but she couldn’t find anyone who would accept her insurance and was taking new patients. “It’s such a daunting experience for someone who has trouble maintaining their home and holding a job and friendships,” says Carlin. “It makes me feel like no one can help me, and I’m not good enough and it’s not an attainable goal.”

save up between sessions. She has just enough to cover a visit once every few months. “I make $30,000 a year,” Carlin says. “I can’t afford an out-of-pocket therapist or psychiatrist. I just can’t afford it. I’m choosing groceries over a therapist.” Angela Kimball, the director of advocacy and public policy at the National Alliance on Mental Illness, says she worries many patients like Carlin simply forgo treatment entirely. “One of the most common reasons people give of not getting mental health treatment is the cost,” Kimball says. “The other is not being able to find care. It’s hurting people in every corner of this nation.”

In Virginia, the Milliman report found that 26 percent of behavioral health office visits were out-of-network — more than seven times more than for medical care. With no alternative, Carlin stuck with her old therapist but now has to

MENTAL

OVERVIEW RESEARCH SWOT SOURCES

STATE JUMPSTARTS EFFORT TO REBUILD INPATIENT PSYCHIATRIC CARE IN MICHIGAN Sarah Cwiek 2/15/2018

SUMMATION + The state of Michigan in the 1990’s shut down most psychiatric facilities and hospitals cut back on the number of hospital beds for mental patients. However, lately there has been a push to revive Michigan’s psychiatric care and currently gathering data and numbers on the places that need it the most.

The state says it’s taking new steps to fix Michigan’s serious lack of inpatient psychiatric care, in hopes of jump-starting a more comprehensive fix. Michigan largely shut down its inpatient psychiatric facilities in the 1990s. Rather than picking up the slack, community hospitals cut back too. That means there’s now a serious shortage of beds for people who need care for an acute psychiatric crisis. A state-convened workgroup just issued a report with 41 recommendations for fixing the problem. Those recommendations run the gamut from relatively simple and easy to implement, to longer-term fixes that will require substantial funding and coordination. Among them, “One of the recommendations that came forward and sort of rose to the top was creating a psychiatric bed registry,” said Phil Kurdunowicz, an analyst with the Michigan Department of Health and Human Services. Kurdunowicz said that online registry would “identify available beds at different inpatient psychiatric units across the state, and help facilitate the transfer of individuals who are in psychiatric crisis into those beds.”

There are other information gaps. Kurdunowicz said there’s preliminary data to suggest which communities and sub-populations face the direst shortages, but we still need “a better picture of where need is the greatest.” “Where are the shortages the greatest, and then how we develop the capacity to serve people in those shortage areas?” Kurdunowicz said. “Do we need to build more state capacity, especially up north, or are there are different solutions that we need to implement around health information technology?” Those questions about larger fixes — and how they’ll be funded — are ones MDHHS plans to deal with down the road. In the meantime, the agency has selected 19 short-term recommendations to implement this year. MDHHS spokesperson Lisa Sutfin says those are mostly policy changes MDHHS can make that set new rules for providers and insurers. They range from reimbursement formula changes and common assessment forms, to requiring children’s hospitals to maintain child and adolescent psychiatric programs.

MENTAL MICHIGAN’S MENTAL HEALTH CARE SHAME Jack Lessenberry 2/20/2018

SUMMATION + The American mental health care “system” is a fractured entity and no one facility or program is able to contain all the community needs and health support they need.

OVERVIEW RESEARCH SWOT SOURCES

When I was a child growing up in the Detroit area in the 1960s, all the kids knew what happened if you became mentally ill, or as we so nicely put it, went nuts. You would be taken to Eloise, which we vaguely knew of as a huge mental institution somewhere. Indeed, there was a mental hospital with the quaint name Eloise in western Wayne County, part of a sprawling complex that once housed thousands of patients. Michigan has very few government mental facilities now; instead, our mentally ill are either living homeless on the streets or are housed at huge expense in our prisons. This is a public health disaster. Last week, my attention was drawn to a story Michigan Radio reported that said the state was taking new steps to rebuild inpatient psychiatric care in Michigan. That would be an excellent idea, but I didn’t believe it for a minute. Rebuilding a state psychiatric care system would be expensive, and we have a legislature which won’t even raise taxes to properly fix the roads, even though that would have overwhelming public approval. Tom Watkins is about as well positioned as anyone to assess the situation. “You are right to be skeptical,” he told me. Watkins was director of what was the state mental health department thirty years ago, and just finished a four-year stint as president and CEO of the Detroit Wayne Mental Health Authority. Watkins told me that the idea that there was a mental health “system” in Michigan, or the nation, was a joke. “We have a disjointed collection of too few state hospitals and private hospitals that are seeking to profit off public patients and hence don’t want those that are too sick, aggressive, and non-compliant.” Additionally, there are too few state or local resources directed at developing community-based programs. Cuts to the Affordable Care Act, which did provide some resources to fill in mental health gaps, are adding to the chaos. The bottom line is that there is no one agency that can hold the multiple fragments of our mental health care network responsible. The result is that it is next to

impossible to find a psychiatric hospital bed for a patient who clearly needs hospitalization. Those angry at this often blame John Engler, who closed a number of state psychiatric facilities soon after he became governor. But the problem started long before, longtime Wayne County Probate Judge Milton Mack told me. Mack, now Michigan’s state court administrator, said the problem began when Congress passed the Community Mental Health Act of 1963. It provided an incentive for states to close state-funded mental hospitals while promising to fund community-based mental health centers and programs to provide outpatient treatment. The facilities were closed. But the funds for the mental health centers never materialized, leaving us with our current mess, which Watkins believes is also a ticking time bomb. He thinks our mental health crisis is “unlikely to truly be addressed until a sensational tragedy erupts.” “Public policy by tragedy, as we are once again witnessing in Parkland, Florida, is not a sensible way to govern,” he said. But as he noted, the real tragedy is already with us, in the thousands of people with serious mental illness who are not properly being served.

MENTAL FATAL RUN-INS BETWEEN COPS, MENTALLY ILL RAISE WORRIES George Hunter 2/5/2018

SUMMATION + People suffering from mental illness are not receiving proper treatment and end up on the streets. These individuals end up having run-ins with the police which can escalate quickly leading to injury or fatalities. Contained are detailed accounts of police run-ins with mentally unstable persons.

OVERVIEW RESEARCH SWOT SOURCES

When police officers cross paths with the mentally ill, the results can be tragic. Police, mental health experts and relatives of people with mental illnesses describe a common cycle: A patient who needs long-term treatment is turned away because there’s no bed space, sending him back onto the streets, where he encounters police. Those confrontations can be dangerous — or deadly — for both officers and citizens. At least five police officers have been shot since 2016 in Detroit, three fatally, by mentally ill suspects. Nationwide, people with untreated mental illnesses are 16 times more likely to be killed by police than other citizens, according to a 2015 Treatment Advocacy Center study. “We have an epidemic in Michigan and across the nation of people with mental illness making contact with law enforcement,” said Mark Reinstein, president of the Mental Health Association in Michigan, an Okemos-based policy analysis and advocacy group. “It’s disheartening that so many of our people get into trouble, often because their mental illness isn’t under treatment,” Reinstein said. “It’s unfortunate for the person suffering from mental illness, and it’s extremely hard on law enforcement.” On Jan. 24, a man who reportedly suffers from mental illness fatally shot Detroit police officer Glenn Doss. Police say Decharlos Brooks, 43, called 911 to report a domestic disturbance. When Doss and other officers arrived, Brooks allegedly opened fire, shooting Doss in the head. The 25-year-old officer died after four days in Detroit Receiving Hospital. Brooks, who according to Detroit police chief James Craig is mentally ill, is charged with murder and is in the Wayne County Jail awaiting trial. “I’ve seen this play out too many times,” said Craig, whose best friend, Los Angeles SWAT officer Randy Simmons, was killed in 2008 by a mentally ill man. “There will be some type of disturbance, where we have to go in and stabilize the situation,” Craig said. “Because the officers are dealing with a mentally ill person, the situation often gets escalated, and someone

MENTAL gets hurt or killed. “Even if there isn’t a violent encounter, if we make the determination that a person is a danger to self or others, we put them in a 72-hour hold. They’re usually given initial treatment and then released, only to go back onto the streets and engage in more criminal activity.” That criminal activity often lands them in jail. “We’re probably the largest mental health institution in Michigan, which is unfortunate,” said Wayne County Sheriff Benny Napoleon, who said 27 percent of the county’s jail inmates are taking psychotropic medication — with countless others suffering from undiagnosed and untreated mental problems. Oakland County Sheriff Michael Bouchard said the number of mentally ill inmates in his jail has skyrocketed over the past 20 years. “When I started 20 years ago, 8 percent of our population was on psychotropic medication; now it’s 30-plus percent,” Bouchard said. “The continuum of mental health services has whittled over time, and as a result, jails have become the de facto dumping ground. We’re not suited for treatment, so ‘dumping ground’ is the only thing to call it.” Former Detroit police officer Antoinette James said her 23-year-old daughter Erica Hayes has been in and out of jails and hospitals after being diagnosed with narcotics-induced bipolar schizophrenia. “I’ve tried to get her into long-term inpatient treatment, but it’s a revolving door,” James said. With no long-term beds available, James cared for her daughter, who went missing Jan. 17. Hayes told her mother she was stepping outside Greater Grace Temple on Seven Mile to smoke a cigarette. She hasn’t been heard from since. “She was on several medications, so I’m worried,” James said. “Today I heard there were three bodies found. It makes you think ‘Lord, I hope it’s not my daughter.’ But they identified the bodies; it wasn’t her.” Reinstein said while the problem is nationwide, people in Michigan have a particularly difficult time getting mental

OVERVIEW RESEARCH SWOT SOURCES

health treatment. “According to the Treatment Advocacy Center, we’re one of the five worst states in the country in our per-capita percentage of state-operated psychiatric hospital beds,” Reinstein said. “And those beds are filled to a large degree with forensic patients,” those awaiting diagnoses to determine if they’re mentally fit to stand trial. “Even when those hospitals take our people, the stays are too short to stabilize them,” Reinstein said. “We surveyed the community mental health boards in Michigan three years ago, and the average length of stay for their clients in community and private psychiatric hospitals was between six and seven days, and many are out in three or four days. That’s just not enough.” Marjorie Lesko said she got down on her knees and begged a staffer at University of Michigan Medical Center to admit her son, Lane, who had Asperger syndrome, a form of autism spectrum disorder, and bipolar mania. Lane Lesko, 19, wasn’t admitted to the hospital. On June 21, 2016, he was killed by a New Hampshire police officer after he brandished a BB gun that resembled a semi-automatic pistol. “Lane was as much a victim of the cop’s bullet that killed him as he was of the mental health system that killed him,” Marjorie Lesko said. Lane Lesko had stolen a car and led police on a chase before reportedly pulling out the BB gun. The New Hampshire Attorney General’s Office ruled the shooting was justified. Lesko believes her son would be alive if he’d gotten the treatment he needed. “It was almost impossible to get treatment,” she said. “My son wanted help. He was Dr. Jekyll and Mr. Hyde.” Wayne State police officer Chris Powell said he regularly encounters people suffering from mental illnesses, both on campus and in the nearby Cass Corridor. “We deal with people who are off their meds, and when that’s the case, someone who may not be violent normally can become violent very easily,” he said. “We have no way of knowing they’re mentally ill when we’re faced with that situation.” The issue strikes a nerve with Powell, whose

best friend, former Wayne State officer Collin Rose, was killed Nov. 22, 2016, by Raymond Durham, a mentally ill homeless man. Four months later, prosecutors say Durham shot Detroit officers James Kisselburg and Ben Atkinson, who are recovering from their injuries. Durham was arrested and charged with first-degree murder, but the Michigan Forensic Center ruled him incompetent to stand trial. Wayne County prosecutors asked for an independent evaluation. Durham is scheduled for another competency review on Friday. “That’s the downfall of our profession: We never know what we’re dealing with,” Powell said. “I can envision how Collin’s encounter went down; (Durham) was out on the streets, living in an abandoned car. We’ve all had that situation so many times. But (Durham) just didn’t want to go to jail that night, and it turned into a violent encounter. “It’s frustrating dealing with mentally ill people, when we aren’t equipped for that. It’s not fair to them, and it’s not safe for us.”

NUTRITION AMERICAâ&#x20AC;&#x2122;S HEALTH RANKINGS 2017

SUMMATION + Various rankings about Michigan health, specifically on obesity rates.

OVERVIEW RESEARCH SWOT SOURCES

NUTRITION SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM USDA 2018

SUMMATION + The United States Department of Agriculture Food assistance program SNAP. Provides assistance to low income families by proving economic benefits.

SNAP offers nutrition assistance to millions of eligible, low-income individuals and families and provides economic benefits to communities. SNAP is the largest program in the domestic hunger safety net. The Food and Nutrition Service works with State agencies, nutrition educators, and neighborhood and faith-based organizations to ensure that those eligible for nutrition assistance can make informed decisions about applying for the program and can access benefits. FNS also works with State partners and the retail community to improve program administration and ensure program integrity.

OVERVIEW RESEARCH SWOT SOURCES

SNAP Participation UNITED STATES

2016

Persons Participating Households Participating Total Issuance

44,219,363 21,777,938 $66,539,351,219

Fraud Investigations Fraud Pre-Certification Fraud Post-Certification

963,965 $376,014,723 $216,700,603

Disqualified

55,930

MICHIGAN

2016

Persons Participating Households Participating Total Issuance

1,473,614 777,906 $2,167,714,845

Fraud Investigations Fraud Pre-Certification Fraud Post-Certification

40,716 $4,584,745 $15,446,571

Disqualified

4,002

Stats from the US SNAP program archives. Includes number of people / households participating. Total amount of money issued to recipients, as well as the number of frauds and how much money was taken due to fraud. Finally the number of people disqualified from the SNAP program.

NUTRITION MDHHS FOOD ASSISTANCE PROGRAM 2016 - 2018

SUMMATION + The MDHHS stats of food assistance in Michigan + Wayne County.

FAP Information MICHIGAN 2018 Cases 698,903 Recipients 1,314,863 Adults 783,666 Children 531,197 Payments $162,443,075 Avergae Per Case $232 Average Per Person $124 WAYNE COUNTY

2018

Cases 229,315 Recipients 430,820 Adults 248,559 Children 182,261 Payments $56,978,595 Avergae Per Case $248 Average Per Person $132

OVERVIEW RESEARCH SWOT SOURCES

NUTRITION

OVERVIEW RESEARCH SWOT SOURCES

TRUMP’S PROPOSAL FOR READY-TO-EAT MEAL KITS Alan Bjerga 2/13/18

SUMMATION + Trump is proposing a replacement to the SNAP program with the use of meal kits. Food is delivered in boxes with weighted amounts of food depending on the family.

In what would be one of the biggest shakeups of the U.S. food-stamp program in its five-decade history, President Donald Trump is proposing to slash cash payments and substitute them with “100 percent American grown food” given to recipients. The changes, outlined Monday in Trump’s budget proposal, would reshape the Supplemental Nutrition Assistance Program, or SNAP, which supports roughly one in eight Americans, by reducing cash spending by about one-third from current levels. The plan is part of an effort to reform SNAP and save a projected $214 billion over a decade. It would give all households receiving more than $90 a month in cash a food-aid package that would “include items such as shelfstable milk, ready to eat cereals, pasta, peanut butter, beans and canned fruit, vegetables, and meat, poultry or fish,” according to the proposal. Shares of Dollar Tree Inc. and Dollar General Corp. both dropped on Monday after the plan was unveiled. The so-called USDA America’s Harvest Box “is a bold, innovative approach to providing nutritious food to people who need assistance feeding

themselves and their families — and all of it is home grown by American farmers and producers,” Agriculture Secretary Sonny Perdue said in a statement. The program would provide food-stamp recipients with “the same level of food value” as the current system, Perdue added. Reaction was muted on Capitol Hill, where both congressional agriculture committees are working on reauthorizations of the food stamp program as part of a farm law that expires Sept. 30. “The task at hand is to produce a Farm Bill for the benefit of our farmers, ranchers, consumers and other stakeholders,” House Agriculture Committee Chairman Michael Conaway of Texas and Senate Agriculture Committee Chairman Pat Roberts of Kansas, both Republicans, said in a joint statement. “This budget, as with every other president’s budget before, will not prevent us from doing that job.” USDA Programs The food stamp program served 42.2 million people and 20.9 million households on average during the 2017 fiscal year. The average household benefit was $254.14, thus 81 percent of homes receiving aid would be included in the initiative, according to the USDA. SNAP

assistance cost $68.1 billion in 2017, with $63.7 billion given out as benefits. Under the plan, the amount of food a household receives would be scaled to the size of the allotment, with about half of the assistance coming as food instead of cash. The USDA already buys commodities for other programs, such as the National School Lunch Program, and states would largely be in charge of distribution, the department said. “States can distribute these boxes through existing infrastructure, partnerships, and/or directly to residences through commercial and/or retail delivery services,” the department said in a statement.

The plan would replace a system that’s working “with a Rube-Goldberg designed system of commodity distribution via food boxes that will be administratively costly, inefficient, stigmatizing, and prone to failure,” Jim Weill, president of the Washingtonbased Food Research & Action Center, said in a statement.

The USDA also touted tightened eligibility rules for recipients, such as stricter work requirements, as well as changing income and benefits calculations “to ensure benefits are targeted to the neediest households.” Major agricultural and food lobby groups refrained from comment, while one anti-hunger group was alarmed at the proposal.

NUTRITION

OVERVIEW RESEARCH SWOT SOURCES

A FOOD TRUCK SERVES THE FORGOTTEN John Carlisle 2018

SUMMATION + A Salvation Army food truck goes around local neighborhoods in Detroit serving food to the poor. It is a system to help the community and the homeless / hungry.

Maybe his crack-smoking brother would be there tonight, he thought. Maybe this would be his chance to save him. Gregory Taylor was behind the wheel of the Salvation Army’s Bed and Bread truck, a mobile food pantry that drives though the poorest neighborhoods in Detroit to bring meals to people who are hungry. It was near the end of a long day, the final stretch of his eight-hour route. The truck was pulling up to one of its last stops, a short street called Zender Place, which has a mix of crumbling houses and occupied homes fronted by a corner park that’s favored by drug addicts and littered with empty liquor bottles and hypodermic needles. “Welcome to Zender Pl. A great place!” says a hand-painted sign in the grass along the curb, a remnant from the neighborhood’s better days. Taylor, 62, had already fed hundreds of people that day at several stops along the route, identified on a clipboard by the intersections where the truck parks — crossroads familiar to longtime Detroiters for their associations with crime and blight. Mack and Bewick. Harper and Cadillac. French Road and Shoemaker. Now, as the truck approached one of the day’s last

destinations, Taylor wondered whether he’d run into his long-lost older brother, since this is the neighborhood where he hangs out, scores drugs, drifts without purpose. His brother was once a wealthy man, a local minister who operated a church and three homeless shelters when his life was at its peak. He made the news 25 years ago when he got on a loudspeaker and calmed an angry mob protesting the beating death of Malice Green by Detroit police before the swelling crowd got violent. By contrast, Taylor’s life was in the gutter back then. He was in and out of jail, wandering the streets, drunk and high on drugs, eating free meals from this very same Salvation Army truck, while his rich-and-famous preacher brother was cajoling him, trying to entice him into straightening his life out with the promise of a Mercedes. “He would send me pictures when I was locked up saying, ‘This is the one you’re going to drive when you get out,’” Taylor said. Just a few years later, in almost mythic irony, they’d switched places in life. Taylor got religion, got out of jail, got clean and got married, while his brother’s taste for the high life

sent him down a spiral that left him a homeless drug addict, the very kind of person he once housed in his shelters. Once in a while, among all those haggard people lining up at the truck to get thin sandwiches and warm soup, Taylor would see his grizzled brother — unshaven, dressed in rags, standing out in the cold, waiting in line with the others. Taylor always pulled him aside, gave him a few bucks, talked to him, tried convincing him to seek treatment to lift himself out of his hell, without much success. Maybe he’d see him again tonight, he thought. Maybe this time it would work. “I won’t lecture him when I’m on the truck,” he said. “But I’ll give him a lecture when I’ve got him by himself.” The truck pulled up to the park. It was crowded with street people. Taylor opened the window, looked out into the shadows and waited.

OPIOID CRISIS

OVERVIEW RESEARCH SWOT SOURCES

DRUG OVERDOSE DEATHS Kaiser Family Foundation 2016

SUMMATION + According to the following statistics, opioids are responsible for 75.8% of all drug overdose deaths in the state of Michigan.

MICHIGAN 2016 2015 Nationwide Overdose Death Average 2015 Michiganâ&#x20AC;&#x2122;s overdose deaths (ranked 15th)

Population: 9,928,000 Prescriptions: 11,000,000 All Drug Overdose Death Rate Opioid Overdose Death Rate Change in Opioid Overdose Death Rate from 2015 Change in All Drug Overdose Rate from 2015

16.5 per 100,000 20.4 per 100,000

24.4 per 100,000 18.5 per 100,000 36% 20%

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

22.0

24.0

26.0

1999

2001

2005

2007

Opioid Overdose Death Rate (Age Adjusted)

2003

2011

2013

Opioid Overdose Death Rate (Age Adjusted)

2009

OVERDOSE DEATH RATES PER 100,000 POPULATION

2015

2016

OPIOID CRISIS

OVERVIEW RESEARCH SWOT SOURCES

DRUG OVERDOSE DEATHS: www.gdahc.org 2016

SUMMATION + “Wayne County Executive Warren Evans called the opioidrelated addictions and deaths a ‘full-blown health crisis from which the drug companies have made billions.’”

WAYNE COUNTY 2016 Population:

1,749,366

Drug Related Deaths: 817 All Drugs

312 Heroin

210 Other Opioids

Percentage of 817 Drug Deaths (Drug Classes): Fentanyl 50.4% Heroin 38.2% Other Opioids 25.7% Carfentanil (Synthetic Analog) 12.2% Caucasian Decedents Vs. African American Decedents: Caucasian African American

531 Deaths 253 Deaths

40.1 Mean Age 50.1 Mean Age

OPIOID CRISIS THE NEUROBIOLOGY OF OPIOID DEPENDENCE Thomas R. Kosten, M.D. Tony P. George, M.D. 2002

SUMMATION + This article discusses the science behind how opioids affect the brain as well as various treatment methods.

OVERVIEW RESEARCH SWOT SOURCES

ABSTRACT Opioid tolerance, dependence, and addiction are all manifestations of brain changes resulting from chronic opioid abuse. The opioid abuser’s struggle for recovery is in great part a struggle to overcome the effects of these changes. Medications such as methadone, LAAM, buprenorphine, and naltrexone act on the same brain structures and processes as addictive opioids, but with protective or normalizing effects. Despite the effectiveness of medications, they must be used in conjunction with appropriate psychosocial treatments. While the individual patient, rather than his or her disease, is the appropriate focus of treatment for opioid abuse, an understanding of the neurobiology of dependence and addiction can be invaluable to the clinician. It can provide insight about patient behaviors and problems, help define realistic expectations, and clarify the rationales for treatment methods and goals. As well, patients who are informed about the brain origins of addiction can benefit from understanding that their illness has a biological basis and does not mean they are “bad” people. Brain abnormalities resulting from chronic use of heroin, oxycodone, and other morphine-derived drugs are underlying causes of opioid dependence (the need to keep taking drugs to avoid a withdrawal syndrome) and addiction (intense drug craving and compulsive use). The abnormalities that produce dependence, well understood by science, appear to resolve after detoxification, within days or weeks after opioid use stops. The abnormalities that produce addiction, however, are more wide-ranging, complex, and long-lasting. They may involve an interaction of environmental effects— for example, stress, the social context of initial opiate use, and psychological conditioning—and a genetic predisposition in the form of brain pathways that were abnormal even before the first dose of opioid was taken. Such abnormalities can produce craving that leads to

ORIGINS OF DRUG LIKING Many factors, both individual and environmental, influence whether a particular person who experiments with opioid drugs will continue taking them long enough to become dependent or addicted. For individuals who do continue, the opioids’ ability to provide intense feelings of pleasure is a critical reason. When heroin, oxycodone, or any other opiate travels through the bloodstream to the brain, the chemicals attach to specialized proteins, called mu opioid receptors, on the surfaces of opiate-sensitive neurons (brain cells). The linkage of these chemicals with the receptors triggers the same biochemical brain processes that reward people with feelings of pleasure when they engage in activities that promote basic life functions, such as eating and sex. Opioids are prescribed therapeutically to relieve pain, but when opioids activate these reward processes in the absence of significant pain, they can motivate repeated use of the drug simply for pleasure. One of the brain circuits that is activated by opioids is the mesolimbic (midbrain) reward system. This system generates signals in a part of the brain called the ventral tegmental area (VTA) that result in the release of the chemical dopamine (DA) in another part of the brain, the nucleus accumbens (NAc) (Figure 1). This release of DA into the NAc causes feelings of pleasure. Other areas of the brain create a lasting record or memory that associates these good feelings with the circumstances and environment in which they occur. These memories, called conditioned associations, often lead to the craving for drugs when the abuser reen-counters those persons, places, or things, and they drive abusers to seek out more drugs in spite of many obstacles. Particularly in the early stages of abuse, the opioid’s stimulation of the brain’s reward system is a primary reason that some people take drugs repeatedly. However, the compulsion to use opioids builds over time to extend beyond a simple drive for pleasure. This increased compulsion is related to tolerance and dependence.

OPIOID TOLERANCE, DEPENDENCE, AND WITHDRAWAL From a clinical standpoint, opioid withdrawal is one of the most powerful factors driving opioid dependence and addictive behaviors. Treatment of the patient’s withdrawal symptoms is based on understanding how withdrawal is related to the brain’s adjustment to opioids. Repeated exposure to escalating dosages of opioids alters the brain so that it functions more or less normally when the drugs are present and abnormally when they are not. Two clinically important results of this alteration are opioid tolerance (the need to take higher and higher dosages of drugs to achieve the same opioid effect) and drug dependence (susceptibility to withdrawal symptoms). Withdrawal symptoms occur only in patients who have developed tolerance. Opioid tolerance occurs because the brain cells that have opioid receptors on them gradually become less responsive to the opioid stimulation. For example, more opioid is needed to stimulate the VTA brain cells of the mesolimbic reward system to release the same amount of DA in the NAc. Therefore, more opioid is needed to produce pleasure comparable to that provided in previous drug-taking episodes. Opioid dependence and some of the most distressing opioid withdrawal symptoms stem from changes in another important brain system, involving an area at the base of the brain—the locus ceruleus (LC) (Figure 2). Neurons in the LC produce a chemical, noradrenaline (NA), and distribute it to other parts of the brain where it stimulates wakefulness, breathing, blood pressure, and general alertness, among other functions. When opioid molecules link to mu receptors on brain cells in the LC, they suppress the neurons’ release of NA, resulting in drowsiness, slowed respiration, low blood pressure—familiar effects of opioid intoxication. With repeated exposure to opioids, however, the LC neurons adjust by increasing their level of activity. Now, when opioids are present, their suppressive impact is offset

OPIOID CRISIS by this heightened activity, with the result that roughly normal amounts of NA are released and the patient feels more or less normal. When opioids are not present to suppress the LC brain cells’ enhanced activity, however, the neurons release excessive amounts of NA, triggering jitters, anxiety, muscle cramps, and diarrhea. Other brain areas in addition to the LC also contribute to the production of withdrawal symptoms, including the mesolimbic reward system. For example, opioid tolerance that reduces the VTA’s release of DA into the NAc may prevent the patient from obtaining pleasure from normally rewarding activities such as eating. These changes in the VTA and the DA reward systems, though not fully understood, form an important brain system underlying craving and compulsive drug use. TRANSITION TO ADDICTION As we have seen, the pleasure derived from opioids’ activation of the brain’s natural reward system promotes continued drug use during the initial stages of opioid addiction. Subsequently, repeated exposure to opioid drugs induces the brain mechanisms of dependence, which leads to daily drug use to avert the unpleasant symptoms of drug withdrawal. Further prolonged use produces more long lasting changes in the brain that may underlie the compulsive drug-seeking behavior and adverse consequences that are the hallmarks of addiction. Recent scientific research has generated several models to explain how habitual drug use produces changes in the brain that may lead to drug addiction. In reality, the process of addiction probably involves components from each of these models, as well as other features.

OVERVIEW RESEARCH SWOT SOURCES

DEFINITIONS OF KEY TERMS dopamine (DA) A neurotransmitter present in brain regions that regulate movement, emotion, motivation, and the feeling of pleasure. GABA (gamma-amino butyric acid) A neurotransmitter in the brain whose primary function is to inhibit the firing of neurons. locus ceruleus (LC) A region of the brain that receives and processes sensory signals from all areas of the body; involved in arousal and vigilance. noradrenaline (NA) A neurotransmitter produced in the brain and peripheral nervous system; involved in arousal and regulation of blood pressure, sleep, and mood; also called norepinephrine. nucleus accumbens (NAc) A structure in the forebrain that plays an important part in dopamine release and stimulant action; one of the brainâ&#x20AC;&#x2122;s key pleasure centers. prefrontal cortex (PFC) The frontmost part of the brain; involved in higher cognitive functions, including foresight and planning. ventral tegmental area (VTA) The group of dopamine-containing neurons that make up a key part of the brain reward system; key targets of these neurons include the nucleus accumbens and the prefrontal cortex.

OPIOID CRISIS THE “CHANGED SET POINT” MODEL

The “changed set point” model of drug addiction has several variants based on the altered neurobiology of the DA neurons in the VTA and of the NA neurons of the LC during the early phases of withdrawal and abstinence. The basic idea is that drug abuse alters a biological or physiological setting or baseline. One variant, by Koob and LeMoal (2001), is based on the idea that neurons of the mesolimbic reward pathways are naturally “set” to release enough DA in the NAc to produce a normal level of pleasure. Koob and LeMoal suggest that opioids cause addiction by initiating a vicious cycle of changing this set point such that the release of DA is reduced when normally pleasurable activities occur and opioids are not present. Similarly, a change in set point occurs in the LC, but in the opposite direction, such that NA release is increased during withdrawal, as described above.

OVERVIEW RESEARCH SWOT SOURCES

heroin use, the brain responds to these successive large DA releases by increasing the number and strength of the brakes on the VTA DA neurons. Eventually, these enhanced “braking” autoreceptors inhibit the neurons’ resting DA release. When this happens, the dependent addict will take even more heroin to offset the reduction of normal resting DA release. When he or she stops the heroin use, a state of DA deprivation will result, manifesting in dysphoria (pain, agitation, malaise) and other withdrawal symptoms, which can lead to a cycle of relapse to drug use.

Under this model, both the positive (drug liking) and negative (drug withdrawal) aspects of drug addiction are accounted for. A specific way that the DA neurons can become dysfunctional relates to an alteration in their baseline (“resting”) levels of electrical activity and DA release (Grace, 2000).

A third variation on the set-point change emphasizes the sensitivity to environmental cues that leads to drug wanting or craving rather than just reinforcement and withdrawal (Breiter et al., 1997; Robinson and Berridge, 2000). During periods when the drug is not available to addicts, their brains can remember the drug, and desire or craving for the drug can be a major factor leading to drug use relapse. This craving may represent increased activity of the cortical excitatory (glutamate) neurotransmitters, which drive the resting activity of the DA-containing VTA neurons, as mentioned, and also drive the LC NA neurons. As the glutamate activity increases, DA will be released from the VTA, leading to drug wanting or craving, and NA will be released from the LC, leading to increased opioid withdrawal symptoms.

In this second variant of the changed set point model, this resting level is the result of two factors that influence the amount of resting DA release in the NAc: cortical excitatory (glutamate) neurons that drive the VTA DA neurons to release DA, and autoreceptors (“brakes”) that shut down further release when DA concentrations become excessive.

This theory suggests that these cortical excitatory brain pathways are overactive in heroin addiction and that reducing their activity would be therapeutic. Scientists are currently researching a medication called lamotrigene and related compounds called excitatory amino acid antagonists to see whether this potential treatment strategy really can work.

Activation of opioid receptors by heroin and heroinlike drugs initially bypasses these brakes and leads to a large release of DA in the NAc. However, with repeated

100

101

OPIOID CRISIS COGNITIVE DEFICITS MODEL

The cognitive deficits model of drug addiction proposes that individuals who develop addictive disorders have abnormalities in an area of the brain called the prefrontal cortex (PFC). The PFC is important for regulation of judgment, planning, and other executive functions. To help us overcome some of our impulses for immediate gratification in favor of more important or ultimately more rewarding long-term goals, the PFC sends inhibitory signals to the VTA DA neurons of the mesolimbic reward system. The cognitive deficits model proposes that PFC signaling to the mesolimbic reward system is compromised in individuals with addictive disorders, and as a result they have reduced ability to use judgment to restrain their impulses and are predisposed to compulsive drug-taking behaviors. Consistent with this model, stimulant drugs such as methamphetamine appear to damage the specific brain circuit—the frontostriatal loop—that carries inhibitory signals from the PFC to the mesolimbic reward system. In addition, a recent study using magnetic resonance spectroscopy showed that chronic alcohol abusers have abnormally low levels of gamma-amino butyric acid (GABA), the neurochemical that the PFC uses to signal the reward system to release less DA (Behar et al., 1999). As well, the cognitive deficits model of drug addiction could explain the clinical observation that heroin addiction is more severe in individuals with antisocial personality disorder—a condition that is independently associated with PFC deficits (Raine et al., 2000). In contrast to stimulants, heroin apparently dam-ages the PFC but not the frontostriatal loop. Therefore, individuals who become heroin addicts may have some PFC damage that is independent of their opioid abuse, either inherited genetically or caused by some other factor or event in

102

OVERVIEW RESEARCH SWOT SOURCES

their lives. This preexisting PFC damage predisposes these individuals to impulsivity and lack of control, and the additional PFC damage from chronic repeated heroin abuse increases the severity of these problems (Kosten, 1998). STRESS AND DRUG CRAVING That drug abuse patients are more vulnerable to stress than the general population is a clinical truism. In the research arena, numerous studies have documented that physical stressors (such as footshock or restraint stress) and psychological stressors can cause animals to reinstate drug use and that stressors can trigger drug craving in addicted humans (e.g., Shaham et al., 2000). The likely explanation for these observations is that opioids raise levels of cortisol, a hormone that plays a primary role in stress responses; and cortisol, in turn, raises the level of activity in the mesolimbic reward system (Kreek and Koob, 1998). By these mechanisms, stress may contribute to the abuser’s desire to take drugs in the first place and to his or her subsequent compulsion to keep taking them. PHARMACOLOGICAL INTERVENTIONS In summary, the various biological models of drug addiction are complementary and broadly applicable to chemical addictions. Long-term pharmacotherapies for opioid dependence and addiction counteract or reverse the abnormalities underlying those conditions, thereby enhancing programs of psychological rehabilitation. Short-term treatments for relieving withdrawal symptoms and increasing abstinence are beyond the scope of this article; instead, we refer readers elsewhere for detailed neurobiological explanations of the various nonopioidbased abstinence initiation approaches such as clonidine and clonidine-naltrex-one for rapid detoxification (see O’Connor and Kosten, 1998, and O’Connor et al., 1997).

The medications most commonly used to treat opioid abuse attach to the brain cells’ mu opioid receptors, like the addictive opioids themselves. Methadone and LAAM stimulate the cells much as the illicit opioids do, but they have different effects because of their different durations of action. Naltrexone and buprenorphine stimulate the cells in ways quite distinct from the addictive opioids. Each medication can play a role in comprehensive treatment for opioid addiction.

higher doses produce full suppression of opioid craving and, consequently, opioid-free urine tests (Judd et al., 1998). Patients generally stay on methadone for 6 months to 3 years, some much longer. Relapse is common among patients who discontinue methadone after only 2 years or less, and many patients have benefited from lifelong methadone maintenance.

METHADONE

A longer acting derivative of methadone, LAAM can be given three times per week. Recent concerns about heart rhythm problems (specifically, prolonged QT interval) have limited LAAM’s use (U.S. Food and Drug Administration, 2001). Nevertheless, long-term maintenance on moderate to high doses of LAAM can, like methadone maintenance, normalize physiological functions such as the cortisol stress response (Kling et al., 2000; Kreek, 1992, 2000; Schluger et al., 2001). Dosing with LAAM is highly individualized, and three-timesweekly doses range from 40 mg to 140 mg.

Methadone is a long-acting opioid medication. Unlike morphine, heroin, oxycodone, and other addictive opioids that remain in the brain and body for only a short time, methadone has effects that last for days. Methadone causes dependence, but—because of its steadier influence on the mu opioid receptors—it produces minimal tolerance and alleviates craving and compulsive drug use. In addition, methadone therapy tends to normalize many aspects of the hormonal disruptions found in addicted individuals (Kling et al., 2000; Kreek, 2000; Schluger et al., 2001). For example, it moderates the exaggerated cortisol stress response (discussed above) that increases the danger of relapse in stressful situations. Methadone treatment reduces relapse rates, facilitates behavioral therapy, and enables patients to concentrate on life tasks such as maintaining relationships and holding jobs. Pioneering studies by Dole, Nyswander, and Kreek in 1964 to 1966 established methadone’s efficacy (Dole et al., 1966). As a Drug Enforcement Administration schedule II controlled substance, the medication is administered primarily in federally regulated methadone programs, where careful monitoring of patients’ urine and regular drug counseling are critical components of rehabilitation. Patients are generally started on a daily dose of 20 mg to 30 mg, with increases of 5 mg to 10 mg until a dose of 60 mg to 100 mg per day is achieved. The

LAAM

NALTREXONE Naltrexone is used to help patients avoid relapse after they have been detoxified from opioid dependence. Its main therapeutic action is to monopolize mu opioid receptors in the brain so that addictive opioids cannot link up with them and stimulate the brain’s reward system. Naltrexone clings to the mu opioid receptors 100 times more strongly than opioids do, but it does not promote the brain processes that produce feelings of pleasure (Kosten and Kleber, 1984).

103

OPIOID CRISIS An individual who is adequately dosed with naltrex-one does not obtain any pleasure from addictive opioids and is less motivated to use them. Before naltrexone treatment is started, patients must be fully detoxified from all opioids, including methadone and other treatment medications; otherwise, they will be at risk for severe withdrawal. Naltrexone is given at 50 mg per day or up to 200 mg twice weekly. Patients’ liver function should be tested before treatment starts, as heroin abusers may have experienced elevation of certain liver enzymes (transaminases) caused by infectious complications of intravenous drug use, such as hepatitis (Verebey and Mule, 1986). Unfortunately, medication compliance is a critical problem with naltrexone, because unlike methadone or LAAM, naltrexone does not itself produce pleasurable feelings. Poor compliance limits naltrexone’s utility to only about 15 percent of heroin addicts (Kosten and Kleber, 1984). Naltrexone is also sometimes used to rapidly detoxify patients from opioid dependence. In this situation, while naltrexone keeps the addictive opioid molecules away from the mu opioid receptors, clonidine may help to suppress the excessive NA output that is a primary cause of withdrawal (Kosten, 1990). BUPRENORPHINE Buprenorphine’s action on the mu opioid receptors elicits two different therapeutic responses within the brain cells, depending on the dose. At low doses buprenorphine has effects like methadone, but at high doses it behaves like naltrexone, blocking the receptors so strongly that it can precipitate withdrawal in highly dependent patients (that is, those maintained on more than 40 mg methadone daily).Buprenorphine is expected to be approved by the Food and Drug Administration for the treatment of opioid

104

OVERVIEW RESEARCH SWOT SOURCES

dependence in 2002. Several clinical trials have shown that when used in a comprehensive treatment program with psychotherapy, buprenorphine is as effective as methadone, except for patients with heroin addiction so severe they would require a dose of more than 100 mg daily (Kosten et al., 1993; Oliveto et al., 1999; Schottenfeld et al., 1997). Buprenorphine offers a safety advantage over methadone and LAAM, since high doses precipitate withdrawal rather than the suppression of consciousness and respiration seen in overdoses of methadone, LAAM, and the addictive opioids. Buprenorphine can be given three times per week. Because of its safety and convenient dosing, it may be useful for treating opioid addiction in primary care settings, which is especially helpful since most opioid addicts have significant medical problems (for example, hepatitis B or C and HIV infection). Buprenorphine will be available in 4 mg and 8 mg tablets. A combination tablet with naloxone (Suboxone) has been developed to negate the reward a user would feel if he or she were to illegally divert and inject the medication. The maintenance dose of the combination tablet can be up to 24 mg and used for every-other-day dosing.

105

Addiction treatment programs

Addiction treatment programs (residential, inpatient and IOP); mental health programs/providers; primary care settings

Grounded in learning theory, involving applying nondrug-related reinforcers to increase abstinence.

Promoting abstinence through facilitating client engagement with Twelve Step fellowship groups like AA and NA; teaching the concepts of acceptance, surrender to a Higher Power and the importance of helping others.

Twelve Step Facilitation (TSF)

Addiction treatment programs (residential, inpatient and IOP); mental health programs/providers

Contingency management

Addressing barriers in the client's motivation to change maladaptive behaviors; eliciting rapid and internally motivated change; focusing on empathic communication.

Motivational enhancement therapy (MET)

Addiction treatment programs (residential, inpatient and IOP); mental health programs/providers

Addiction treatment programs

Teaching the client to anticipate problems/risks to relapse and how to address them; recognizing distorted thinking processes and how to correct them; enhancing self-control through coping strategies.

Cognitive-behavioral therapy (CBT)

Settings

Community Reinforcement

Clinical Focus

Approach

Commonly-used psychosocial evidence-based practices for treatment of substance abuse disorders

Butler Center for Research White Paper | October 2017

OPIOID CRISIS HOW OPIOIDS KILL Dina Fine Maron 2018

SUMMATION + What exactly happens in the body during a fatal overdose and why fentanyl is responsible for so many of them.

OVERVIEW RESEARCH SWOT SOURCES

One evening this past fall a patient stumbled into the emergency room at Brigham and Women’s Hospital in Boston. “I don’t feel so…” she muttered, before losing consciousness. Her breathing was shallow and her pupils were pinpoints, typical symptoms of an opioid overdose. Her care team sprang into action. They injected her with 0.4 milligram of naloxone, an overdose antidote—but she remained unresponsive. They next tried one milligram, then two, then four. In total they used 12 milligrams in just five minutes, says Edward Boyer, the physician overseeing her care that night. Yet the patient still had trouble breathing. They put a tube down her throat and hooked her to a ventilator. Twenty minutes later she woke up—angry and in drug withdrawal, but alive. The patient, whose identifying details may have been altered to protect patient confidentiality, had apparently injected herself with a synthetic opioid such as fentanyl right outside of the hospital building. That gave her just enough time to seek help. But many users of synthetic opioids are not so lucky. These drugs, which bear little chemical resemblance to any opioid derived from the opium poppy, are much more powerful than poppy-based heroin and semisynthetic opioids such as oxycodone or hydrocodone. Thus, the standard dose of naloxone employed by first responders (and sold in bystander overdose kits) is often not potent enough to save a synthetic opioid user’s life. Recent data indicate the rise of these synthetics is proving particularly deadly. Between 2015 and 2016 the rate of reported overdose deaths involving synthetic opioids—meaning fentanyl and similar drugs, as well as the painkiller tramadol—doubled, accounting for about 6 deaths per 100,000 people in 2016, and contributing to the more than 63,000 deaths from drug overdoses that year. But how do these drugs actually kill people? When a person smokes, snorts or injects an opioid, the substance enters the bloodstream, then the brain. There it can act on mu-opioid receptors, says Eric Strain, director of the

106

Center for Substance Abuse Treatment and Research at Johns Hopkins University. “Once the drug binds to those opioid receptors and activates them, it sets off a cascade of psychological and physical actions; it produces euphoric effects, but it also produces respiratorydepressing effects,” Strain says. As a result, victims of a fatal overdose usually die from respiratory depression—literally choking to death because they cannot get enough oxygen to feed the demands of the brain and other organ systems. This happens for several reasons, says Bertha Madras, a professor of psychobiology at McLean Hospital and Harvard Medical School. When the drug binds to the mu-opioid receptors it can have a sedating effect, which suppresses brain activity that controls breathing rate. It also hampers signals to the diaphragm, which otherwise moves to expand or contract the lungs. Opioids additionally depress the brain’s ability to monitor and respond to carbon dioxide when it builds up to dangerous levels in the blood. “It’s just the most diabolical way to die, because all the reflexes you have to rescue yourself have been suppressed by the opioid,” Madras says. SAVING LIVES WITH AN OPIOID ANTIDOTE Naloxone can short-circuit that deadly spiral. It races to those same receptors and lies in wait. Then, as soon as an opioid molecule falls off the receptor (as it normally would every few seconds or minutes), naloxone immediately latches on and takes its place before the drug can bind once again. This halts the respiratory-depressing actions— and often sends a user into an agonizing drug withdrawal. But synthetic opioids present two problems that can interfere with Naloxone’s lifesaving process. One is a matter of timing: These substances are so powerful they may act extremely quickly, suppressing a person’s breathing before naloxone has a chance to reach its target. The second issue is potency: The synthetic drugs bind to receptors much more tightly than an opiumderived substance such as heroin or a semisynthetic opioid like oxycodone, so the antidote has difficulty reaching its destination.

So what can be done? To get around these hurdles, doctors may give a patient multiple injections of naloxone—hopefully overwhelming the drugs that are competing for a place at key targets in the brain. The situation at the mu-opioid receptors is akin to a crowd waiting to buy tickets for baseball game, Madras explains. “If 20 Bostonians all want to see a Red Sox game and there are 300 Yankees fans around, the 300 Yankees fans are going to have a 15 times higher probability of getting the tickets to the game because there are so many more of them. It’s not that the Yankees fans are pushing the Red Sox fans out of the way—it’s just that there are much more of them, and so it’s a probability issue.” That numbers issue, combined with the recent spike in synthetic opioid overdoses, has rekindled the debate about adjusting the default amount of naloxone used for overdose. The main question is: To boost the odds this antidote will have a shot at saving someone’s life, should naloxone doses be increased for everyone— basically betting that an apparently overdosed patient has consumed a drug laced with a synthetic opioid such as fentanyl? Some doctors and researchers say yes, and suggest starting patients on two milligrams of the antidote instead of 0.4 milligram. “But now you get into that whole issue of the cost of naloxone and its availability,” Strain notes. (Naloxone is a pricey drug. In Baltimore, for example, it now costs $37.50 per dose, according to the city’s health department.) And there’s another catch: A large dose of naloxone can worsen drug withdrawal. “That’s a danger in of itself, because people who go into withdrawal can vomit and breathe that in, and aspirate on their vomit—choking on it,” Madras says. Moreover, some individuals experiencing withdrawal may get violent, endangering others. A patient suffering from intense withdrawal may also become so ill, it discourages that person from trying to quit and enter into a treatment center, she adds.

107

108

109

ALTERNATE METHODS

OVERVIEW RESEARCH SWOT SOURCES

IS CANNABIS BETTER FOR CHRONIC PAIN THAN OPIOIDS? JEREMY KOSSEN 2016

SUMMATION + This article discusses the use of cannabis in the treatment of chronic pain.

Chronic pain can be an incredibly debilitating condition. For many who live with it on a daily or near daily basis, the condition can be so oppressive, it affects other parts of their lives, impacting their mood, health, and overall well-being. Unfortunately, many treatment options are only nominally effective. Worse, commonly prescribed drugs like opioids are highly addictive and potentially toxic; 28,000 people died from an opioid overdose in 2014, more than any other year in history. No wonder a growing number of the estimated one in five Americans who suffer from chronic pain are turning to cannabis as an alternative. While many people believe cannabis to be an effective treatment, what does the science say? Is it really more effective and safer than other drugs? Fortunately, when it comes to cannabis and cannabinoid-based formulations, chronic pain is one of the best studied conditions. However, the causes of chronic pain are diverse. Moreover, chronic pain can be nociceptive or neuropathic. Nociceptive pain is caused by tissue damage or inflammation. Neuropathic pain is caused by nervous system damage or malfunction. Everyoneâ&#x20AC;&#x2122;s biology is unique and will respond differently to cannabis depending on a number of variables, including what type of chronic pain they experience, dosage, strain, and administration method (vaping, edibles, tinctures, etc.).

110

HOW EFFECTIVE IS CANNABIS FOR CHRONIC PAIN RELIEF? In a comprehensive, Harvard-led systematic review of 28 studies examining the efficacy of exo-cannabinoids (e.g. synthetic formulations or cannabinoids from the plant) to treat various pain and medical issues, the author concluded, “Use of marijuana for chronic pain, neuropathic pain, and spasticity due to multiple sclerosis is supported by high quality evidence.” Of the studies reviewed, six out of six general chronic pain studies and five out of five neuropathic pain studies found a significant improvement in symptoms among patients. Notably, while most of the studies were limited to synthetic preparations of cannabinoids, three of the five neuropathic pain studies investigated “smoked” cannabis, while two examined an oral spray preparation. Dr. Donald Abrams, a professor and Chief of Hematology/ Oncology at San Francisco General Hospital, supports cannabis to treat chronic pain, suggesting the following: “Given the safety profile of cannabis compared to opioids, cannabis appears to be far safer. However, if a patient is already using opioids, I would urge them not to make any drastic changes to their treatment protocol without close supervision by their physician.” Both THC and CBD in cannabis are known to elicit analgesic effects, especially when used together due to their congruent chemical synergies. CANNABIS VS. OPIOIDS North America has been hit hard by the opioid epidemic. Prescriptions have increased 400% percent since 1999, and with this trend a shocking increase in fatal overdoses has followed. Every day, 40 people now die from prescription narcotic overdoses. Many also move on to heroin because it is cheaper, easier to find, and more potent. Could cannabis be part of the solution?

Quite possibly. An increasing number of studies provide evidence that many patients can use cannabis instead of opioids to treat their pain, or they can significantly reduce their reliance on opioids. A University of Michigan March 2016 study published in the Journal of Pain provides some compelling data. They found that cannabis: + Decreased side effects from other medications + Improved quality of life + Reduced use of opioids (on average) by 64% “We are learning that the higher the dose of opioids people are taking, the higher the risk of death from overdose,” said Dr. Daniel Clauw, one of the study’s researchers and a professor of pain management anesthesiology at the University of Michigan Medical School. “[The] magnitude of reduction in our study is significant enough to affect an individual’s risk of accidental death from overdose.” Kevin Ameling, a chronic pain patient who now works for a Colorado-based non-profit cannabis research advocacy group called the IMPACT Network, is a success story. Ameling believes cannabis saved him from a life of dependency on prescription drugs. In 2007, he suffered a severe fall and was prescribed a cocktail of prescription drugs that included OxyContin, Tramadol, Clonazepam, and Lexapro. The pain became so severe that he had to progressively increase dosage while the OxyContin became less and less effective. Living in Colorado, he decided to try medical marijuana in 2013. He claims he achieved results immediately and was able to significantly reduce his prescription intake. He cut his OxyContin dosage by 50%, reduced Clonazepam from 3 mg to 0.5 mg, Lexapro from 30 mg to 5 mg, and Tramadol from 300 mg to 75 mg.

111

ALTERNATE METHODS

OVERVIEW RESEARCH SWOT SOURCES

WILL PSYCHEDELIC THERAPY TRANSFORM MENTAL HEALTH CARE? JOSEPH BENNINGTON-CASTRO 2017

SUMMATION + This article discusses the potential of psychedelic drugs in the mental healthcare system to relieve addiction, anxiety and depression.

In the mid-1950s, LSD and other psychedelic drugs took the medical world by storm — and no wonder. Studies at the time suggested that the hallucinogens were effective against a variety of difficult-to-treat mental health problems, including alcoholism. The research stalled in the early 1970s, however, in large part because psychedelics had developed a reputation as dangerous recreational drugs and had been reclassified by the federal government as “drugs of abuse” with no medical value. But research is picking up again, with new trials not just of LSD but also of psilocybin (the active compound in magic mushrooms), MDMA (street name “ecstasy”), and ayahuasca (a South American brew containing a hallucinogen known as DMT). If the drugs prove to be as safe and effective as recent research suggests, we may be on the brink of what some are calling a revolution in mental health care. “Psychedelics, under carefully controlled conditions, can create experiences of wonder and awe and a connection to a ‘divine realm’ that leads to significant behavioral changes,” says ayahuasca expert Kenneth Tupper, director of implementation and partnerships at the British Columbia Centre on Substance Use. “Psychedelic drugs are not a panacea, but the research is showing a lot of promise.”

112

MULTIPLE DRUGS, MULTIPLE BENEFITS

SAFETY FIRST

Just what can the drugs do? A single treatment with psilocybin has been shown to relieve crippling anxiety in people with terminal cancer. The drug has also been shown to be an effective therapy for substance use disorders. MDMA can provide valuable help to people suffering from post-traumatic stress disorder (PTSD).

Psychedelic drugs fall into one of two categories depending on how they affect the brain.

And there’s more. Preliminary evidence suggests that psychedelic drugs can be effective for eating disorders, obsessive-compulsive disorder, and major depression — including cases that don’t respond to conventional antidepressants. The drugs may also be good for helping smokers kick the habit, a process that’s often notoriously difficult via conventional means. If the research pans out, the world of mental health care may look very different in the coming decades. Psychedelic treatment won’t be available for just anyone, and recreational psychedelic use may still be banned. But those with certain illnesses could seek treatment from a psychiatrist specially certified in psychedelic therapy. Just a few treatment sessions a year might be enough to provide lasting relief from their issues. People with mood disorders, including those who are unresponsive to conventional therapies, might be able to ditch their antidepressants and antianxiety medications. Those with terminal illness could enjoy their remaining days without the fear of death looming over them, while people with PTSD could return to a normal life unobstructed by paralyzing flashbacks. And rehab centers for substance use and eating disorders could empty out as more people turn to psychedelics. Again, we’re not at this point yet. But such is the promise of psychedelic medicine.

Classic psychedelics include LSD, psilocybin, and ayahuasca. They work by binding to the same receptors in the brain as serotonin, a neurotransmitter associated with feelings of wellbeing. MDMA, on the other hand, causes the release of another neurotransmitter, serotonin, in the brain. At this point, the star players in psychedelic research are psilocybin and MDMA. (LSD’s hallucinogenic effects last too long, thus limiting its therapeutic value; ayahuasca is hard to standardize because it’s a brew made from two plants.) Given psychedelics’ potential for abuse — and the possibility of unpleasant hallucinations — clinical trials of the drugs follow rigid protocols. Patients for the clinical trials are screened for schizophrenia and related disorders that preclude psychedelic therapy; those who are selected undergo preliminary sessions during which they learn about the goals and nature of the treatment, as well as the particulars of the drug they’ll be trying. During treatment, patients typically don headphones for music and eyeshades and then lie down. They’re encouraged to go as “deep” as possible into the experience, says Charles Grob, a UCLA psychiatry professor who has done research on MDMA, psilocybin, and ayahuasca. As the session ends and the hallucinogenic effects wear off, patient and therapist discuss the experience. Follow-up psychotherapy sessions facilitate lasting results, Grob says. As experimental therapies, the sessions are conducted in research labs under medical supervision. Psychedelic therapy is not yet available in therapists’ office or other ordinary therapeutic settings.

113

ALTERNATE METHODS WHAT THE RESEARCH SHOWS

Just what do the studies show? In 2010, Grob and his colleagues published a tiny pilot study showing that psilocybin reduced anxiety and depression in patients with advanced-stage cancer, helping them better cope with the fear of death.

OVERVIEW RESEARCH SWOT SOURCES

they can navigate the experience more safely.” In recent clinical trials, 61 percent of 107 participants no longer had PTSD symptoms two months after MDMAassisted psychotherapy. Sixty-eight percent were still PTSD-free a year later. In light of findings like these, the FDA recently deemed MDMA a “breakthrough therapy,” putting it on the fast track for approval.

Recent studies conducted by other research groups have shown similarly promising results. In 2016, for instance, a Johns Hopkins study and a concurrent New York University study found that about 80 percent of cancer patients showed clinically significant decreases in depressed mood and anxiety even six months after receiving one to two psilocybin treatments.

MYSTICISM AND HEALTH

Psilocybin also appears to be an effective treatment for addiction. Echoing past research with LSD, scientists recently showed decreased cravings for and increased abstinence from alcohol after psilocybin treatment in a proof-of-concept study — and the benefits were still in evidence nine months later.

“Unlike almost all other psychiatric medications that have a direct biological effect, these drugs seem to work through biology to open up a psychological opportunity,” says Matthew Johnson, a Johns Hopkins University psychiatrist who heads the university’s Psilocybin Research Project and has conducted psilocybin research.

Psilocybin seems especially promising as a tool for smoking cessation. In a preliminary study of smokers conducted in 2014, 80 percent of participants remained nicotine-free six months after receiving three psilocybin sessions. And 60 percent of the participants remained nicotine-free an average of 30 months after treatment.

And the drugs’ benefits may go beyond simply treating specific disorders. In 2011, Johnson and his colleagues showed that a single psilocybin session can give people a more “open” personality, as well as a greater appreciation of new experiences and enhanced curiosity and imagination. Follow-up research showed that these effects persisted for at least 14 months — and may even be permanent.

Compared with the classic psychedelics, MDMA doesn’t encourage deep introspection, so psychotherapy sessions with the drug often involve much more discussion between doctor and patient. That makes it a good fit for PTSD treatment.

If that makes you eager to give psycheledic therapy a try, you’ll have to wait awhile. The only psychedelic that seems close to clinical use is MDMA (for PTSD), and it needs to go through final trials that are expected to take several years.

“Normally, when someone [with PTSD] would be instructed to relive the traumatic experience, they would be overwhelmed with fear, anxiety, and despair,” Grob says. “But while under the influence of the MDMA, it’s as if

“We’re still at the beginning of this field and the questions are wide open,” Johnson says. “There are hundreds of careers worth of study left to do.”

114

What makes psychedelic therapy so powerful? Experts say it may be because the drugs work on a deep emotional as well as biological level, with patients experiencing a transformative sense of positivity, benevolence, and unity during “trips” that many describe as mystical.

115

ALTERNATE METHODS

OVERVIEW RESEARCH SWOT SOURCES

MAGIC MUSHROOMS CAN OFFER REAL BENEFITS IN DEPRESSION THERAPY MIKE MCRAE 2017

SUMMATION + This article discusses research suggesting that combining therapy with psilocybin can be an effective treatment for depression.

A review of the research on combining therapy with the psychoactive component from magic mushrooms has concluded itâ&#x20AC;&#x2122;s not only a safe and effective way to treat conditions related to anxiety, depression, and addiction, it could be better than many existing forms of treatment. The findings reinforce the need to explore the full impact of the psychedelic compound called psilocybin, a drug that is showing increasing promise in its ability dramatically improve the lives of those who suffer debilitating psychiatric disorders. Psychedelics such as lysergic acid diethylamide (LSD) and psilocybin have a reputation more as a party drug than as forms of therapeutic medication. But their similarity to neurotransmitters such as serotonin and their ability to affect our perception and mess with our state of consciousness has made them attractive candidates for treating various psychiatric conditions. Studies have found patients with severe depression have improved after taking small amounts of psilocybin alongside supportive therapy sessions, with evidence that their brains have strengthened links across previously disconnected regions.

116

These kinds of results demand attention, demonstrating great potential for using serotonin agonists such as psilocybin to block problematic networks in the brain while therapy can be used to create more functional ones.

“The clinical trials summarised were Phase 2 studies investigating safety and efficacy endpoints, but some of the studies were open-label and lacked statistical analysis,” says Thomas.

A review by researchers in California has shown such studies aren’t outliers, prompting a need to step forward with testing. Their analysis of seven clinical trials conducted over the past decade testing the effects of psilocybin-assisted therapy on anxiety, depressive disorders, addiction, and obsessive-compulsive disorder has shown the drug.

Phase 3 trials would establish the drug’s actual effectiveness and comparative value as a bona fide treatment, bringing it one giant step closer to being an option for licensed and trained psychiatrists to use with patients. One advantage of such rigorous testing of pharmaceuticals such as psilocybin is the establishment of evidence challenging decades of negative association as illicit and therefore harmful substances. Methylenedioxymethamphetamine (MDMA) is the active component in what’s commonly called ecstasy, a drug that’s come in and out of fashion on the dance club scene since the 1980s.

“Psilocybin-assisted therapy has been shown to be safe in several studies across a variety of patient populations,” researcher Kelan Thomas of Touro University California explained to Eric W. Dolan of PsyPost. Compared with other forms of treatment on validated psychiatric rating scales, therapy with psilocybin has resulted in a larger effect, suggesting it could be a better option for many patients, especially those who have failed to respond to other medications or procedures. “One important distinction from these other sessionbased treatments would be that the benefits of psilocybin-assisted therapy may only require a few dosing sessions and the effects appear to persist longer than other treatment options,” the researchers write in their report. This isn’t to say the drug can be beneficial independently as a form of medication – research on the therapeutic impact of psychoactive drugs is pretty thin on the ground due to ethical constraints, but that also means there’s no strong evidence supporting use of psilocybin without the support of therapy sessions.

Studies have also demonstrated its effectiveness in treating conditions associated with everything from autism spectrum disorder to post-traumatic stress, but like psilocybin, there are years of testing and biases to overcome before we’ll be seeing its full potential as a form of medication. Changing attitudes and laws towards cannabis as a valid treatment could well open the way for other psychoactive substances to be seen in a new light. This research was published in the Journal of Psychoactive Drugs.

It is a good reason to now conduct larger trials with more powerful statistical tools to aim for getting the US Food and Drug Administration’s big tick of approval.

117

ALTERNATE METHODS

OVERVIEW RESEARCH SWOT SOURCES

LSD-ASSISTED PSYCHOTHERAPY www.maps.org 2018

SUMMATION + This article discusses the history of the use of LSD in psychotherapy and a recent study conducted by MAPS.

MAPS has completed the first double-blind, placebo-controlled study of the therapeutic use of LSD in human beings since the early 1970s. LSD (lysergic acid diethylamide) is a semi-synthetic compound first developed in 1938 by Dr. Albert Hofmann at the Sandoz pharmaceutical company in Basel, Switzerland. After Dr. Hofmann first discovered its effects in 1943, LSD quickly became recognized for its possible therapeutic effects. LSD also played a significant role in the discovery of the serotonin neurotransmitter system. Our completed Phase 2 pilot study in 12 subjects found positive trends in the reduction of anxiety following two LSD-assisted psychotherapy sessions. The study results also indicate that LSD-assisted psychotherapy can be safely administered in these subjects, and justify further research. LSD is known for its ability to catalyze spiritual or mystical experiences and to facilitate feelings of interconnection. MAPS is interested in this substance for its potential to help people with a variety of conditions, focusing primarily on the treatment of anxiety associated with life-threatening illness, as well as for spiritual uses, creativity, and personal growth. There is considerable previous human experience using LSD in the context of psychotherapy. From the 1950s through the early 1970s, psychiatrists, therapists, and researchers administered LSD to thousands of people as a treatment for alcoholism, as well as for anxiety and depression in people with advanced stage cancer. MAPSâ&#x20AC;&#x2122; completed and future research conforms to modern drug development standards, and will help guide the development of additional research into the risks and benefits of LSDassisted psychotherapy.

118

The statistical software Statistical Package for the Social Sciences for Windows, version 18.0 (IBM Corp, New York), was used.

Statistical Analysis

30-item version 1.0 (EORTC-QLQ-30; Aaronson et al., 1993), the SCL-90-R (Schmitz et al., 2000), and the Hospital Anxiety and Depression Scale (HADS; Herrmann-Lingen et al., 2011). Outcome measures were completed at baseline, 1 week after experimental sessions, 2-month follow-up, and 12-month follow-up. The participants completed a daily dairy on changes in medication, adverse effects of LSD or medications, and pain using the Visual Analog Pain Scale. After each experimental session, the State of Consciousness Questionnaire was completed (Griffiths et al., 2006).

www.jonmd.com

* 2014 Lippincott Williams & Wilkins

FIGURE 2. Study outcomes. State and trait anxiety scores in the LSD and placebo group. Values are mean T SEM of changes from baseline in eight subjects in the LSD group and three subjects in the placebo group. Measures were obtained before the first treatment session (baseline), 1 week after the first treatment (post 1 LSD), 1 week after the second treatment (LSD 2), and at follow-up after 2 months. At 2 months, state anxiety scores were significantly lower in the LSD group compared with the placebo group. The crossover group (n = 3) shows a positive trend of STAI state and trait score reduction. At 12-month follow-up, the state and trait values remain stable compared with the 2-month follow-up.

LSD-assisted experimental session was focused inward with music played to deepen self-awareness and facilitate emotional processing, and one third contained brief conversations. The therapeutic session ended after 8 hours, when the acute effects had subsided, followed by a brief review of the dayâ&#x20AC;&#x2122;s experiences. After each experimental session, three drug-free psychotherapy sessions lasting 60 to 90 minutes took place, during which the participantâ&#x20AC;&#x2122;s experiences were reviewed for integration and deepening the therapeutic process. Two months after the second experimental session, a follow-up evaluation was completed, and the treatment period was finished by breaking the blind for each individual. The participants who received the active placebo could cross over to an identical but open-label treatment with 200 Kg of LSD. A long-term

119

ALTERNATE METHODS

OVERVIEW RESEARCH SWOT SOURCES

MDMA-ASSISTED PSYCHOTHERAPY www.maps.org 2018

SUMMATION + This article discusses the potential benefits of MDMA therapy in patients with PTSD and autistic adults with social anxiety.

Phase 3 Trials: FDA Grants Breakthrough Therapy Designation for MDMA-Assisted Psychotherapy for PTSD, Agrees on Special Protocol Assessment. Our highest priority project is funding clinical trials of 3,4 methylenedioxymethamphetamine (MDMA) as a tool to assist psychotherapy for the treatment of posttraumatic stress disorder (PTSD). Preliminary studies have shown that MDMA in conjunction with psychotherapy can help people overcome PTSD, and possibly other disorders as well. MDMA is known for increasing feelings of trust and compassion towards others, which could make an ideal adjunct to psychotherapy for PTSD. We are studying whether MDMA-assisted psychotherapy can help heal the psychological and emotional damage caused by sexual assault, war, violent crime, and other traumas. We are also studying MDMA-assisted therapy for autistic adults with social anxiety, and MDMA-assisted psychotherapy for anxiety related to life-threatening illnesses. MAPS is recruiting subjects for clinical trials. In MDMA-assisted psychotherapy, MDMA is only administered a few times, unlike most medications for mental illnesses which are often taken daily for years, and sometimes forever. MDMA is not the same as “Ecstasy” or “molly.” Substances sold on the street under these names may contain MDMA, but frequently also contain unknown and/or dangerous adulterants. In laboratory studies, pure MDMA has been proven sufficiently safe for human consumption when taken a limited number of times in moderate doses.

120

121

Mean Clinician-Administered PTSD Scale

Placebo MDMA

GROUP

Time

Impact of Events Scale-Revised

Placebo MDMA

GROUP

Time

122

123

124

ANALYSIS

S.W.O.T. ANALYSIS OVERVIEW RESEARCH SWOT SOURCES

125

S.W.O.T.

126

OVERVIEW RESEARCH SWOT SOURCES

STRENGTHS + There are already a lot of plans and programs to help provide people with health care, and many new alternatives that people can consider and look into for medical help.

127

S.W.O.T.

128

OVERVIEW RESEARCH SWOT SOURCES

WEAKNESS + Medical expenses are very high and hard to pay. Nutrition from food is lacking. Mental care is not supported enough. Opioids have become an issue causing addiction and overdoses.

129

S.W.O.T.

130

OVERVIEW RESEARCH SWOT SOURCES

OPPORTUNITY + Thereâ&#x20AC;&#x2122;s opportunities to make some of these concerns more aware to the public. Programs to help people get the proper health care they need, especially for mental care, and addiction, but also help inform and make content more understandable would benefit the community. 131

S.W.O.T.

132

OVERVIEW RESEARCH SWOT SOURCES

THREATS + Medical costs are huge, and a community like Wayne county cannot afford expenses like that. Many residents rely on the ACA for health insurance and if it gets repealed they will lose their coverage.

133

134

LINKS

RESEARCH SOURCES OVERVIEW RESEARCH SWOT SOURCES

135

SOURCES

OVERVIEW RESEARCH SWOT SOURCES

REFRENCES GENERAL LINKS

HEALTH COSTS LINKS

MENTAL LINKS

http://medicare-usage.healthgrove. com/l/1335/Wayne-County

https://www.thebalance.com/causesof-rising-healthcare-costs-4064878

https://www.onhealth.com/content/1/ mental_disorders_in_america

https://aidsvu.org/state/michigan/

https://www.youtube.com/ watch?v=CeDOQpfaUc8

http://www.mlive.com/news/grandrapids/index.ssf/2018/01/eroding_ funding_threatens_ment.html

https://www.census.gov/quickfacts/ fact/table/waynecountymichigan/ PST045217 https://www.griffinbenefits.com/ employeebenefitsblog/history_of_ healthcare http://journaltimes.com/news/timelineus-health-care-reform-efforts-throughhistory/article_859d168c-c131-11e1b40b-0019bb2963f4.html http://healthinsuranceratings.ncqa. org/2017/Default.aspx http://www.michigan.gov/

http://www.bridgemi.com/publicsector/michigan-counties-mostvulnerable-if-obamacare-repealed https://www.vox.com/a/health-prices https://www.vox. com/2014/9/2/6089693/health-carefacts-whats-wrong-american-insurance https://qz.com/1022831/why-doesntthe-united-states-have-universalhealth-care/ https://datausa.io/profile/geo/waynecounty-mi/ https://fns-prod.azureedge.net/sites/ default/files/snap/FY16-State-ActivityReport.pdf

136

https://www.detroitnews.com/story/ news/local/wayne-county/2016/03/17/ report-wayne-worst-healthoutcomes/81909584/ https://www.npr.org/sections/healthshots/2017/11/29/567264925/healthinsurers-are-still-skimping-on-mentalhealth-coverage http://michiganradio.org/post/statejump-starts-effort-rebuild-inpatientpsychiatric-care-michigan http://michiganradio.org/post/ michigans-mental-health-care-shame https://www.detroitnews.com/story/ news/local/michigan/2018/02/05/ conflicts-mentally-worrypolice/110114150/

NUTRITION LINKS

OPIOID + ALTERNATIVES LINKS

http://www.michigan.gov/documents/ dhs/DHS-Trend_Table_24_269236_7. pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/

http://time.com/5155362/trump-cutfood-stamps/ https://www.freep.com/story/news/ columnists/john-carlisle/2017/09/13/ salvation-army-food-truck-detroit-johncarlisle/337775001/ https://www.americashealthrankings. org/explore/2016-annual-report/ measure/Obesity/state/MI https://www.fns.usda.gov/snap/ supplemental-nutrition-assistanceprogram-snap

https://drugabuse.com/take-mybreath-away-a-deadly-warning-aboutopiates/ https://www.scientificamerican.com/ article/how-opioids-kill/ http://www.gdahc.org/sites/default/ files/Setting%20the%20Stage%20Cynthia%20Arfken.pdf https://www.kff.org/other/state-indicator/opioid-overdose-death-rates/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Percent%20 Change%20in%20Opioid%20Overdose%20Death%20Rate%20from%20 Prior%20Year%22,%22sort%22:%22desc%22%7D

137

COLOPHON EDITORS Sean Carbary Dylan Magliocco DESIGN Sean Carbary Dylan Magliocco CHARTS Sean Carbary Dylan Magliocco PROGRAMS USED Adobe Creative Cloud TYPEFACE Avenir Next - Regular, Italic, Demi Bold, Bold PAPER Navajo Smooth Brilliant White 65C, Navajo Smooth Brilliant White 120DTC

138

139

140