NAMI’s Federal Policy Agenda in the Trump Administration Presentation to the NAMI Keystone PA Conference March 13, 2018 Andrew Sperling asperling@nami.org

Is the Glass Half Empty or Half Full?

First, the bad news … Imprecise and faulty diagnostics Mortality from suicide in the US now exceeds breast and prostate cancer Early mortality – life expectancy adults with mental illness in the US just below Bangladesh Progress on new treatments is way too slow, contrast with HIV-AIDS Too many people with serious mental illness in jails and prisons, criminal justice as the default treatment system 1/3 of the SSI rolls, ¼ of the SSDI rolls, sub-poverty level benefits Unstable housing and high representation in the chronic homeless population Not nearly enough inpatient acute care beds – emergency room board

Now, the good news … Recovery is real and achievable We know what works – early intervention can prevent long-term disability assertive community treatment, supportive housing, supported employment, assisted outpatient treatment, peer support, medication, integration of primary and specialty medical care, family psycho-education Mental health has strong bipartisan support in Congress and across the nation – passage of the Helping Families in Mental Health Crisis in 2016

Trump Administration Mental Health Initiatives Appointment and Senate Confirmation of Elinor McCance-Katz, MD as HHS Assistant Secretary for Mental Health & Substance Abuse Convening of the Interdepartmental Serious Mental Illness Coordinating Committee (HHS, HUD, DoL, VA, SSA) – Initial report and recommendations issued on December 14, 2017, NAMI CEO Mary Giliberti is on the outside stakeholder panel July 27, 2017 public meeting on parity implementation and enforcement and additional parity guidance March 12, 2018 announcement on school safety inititaives includes: Integration of mental health, primary care, and family services, as well as support for court-ordered treatment, and Review of FERPA & HIPAA to assess clarifications to improve coordination between mental health, school officials, and law enforcement.

Status of “Repeal & Replace” of the ACA American Health Care Act (HR 1628) passed the House on May 5, 217-213 Better Care Reconciliation Act rejected 49-51 on July 28 Tax penalty for the ACA individual mandate repealed as part of the December 2017 tax cut legislation Cost Sharing Reduction (CSR) subsidies suspended on October 12 Association Health Plan (AHP) rule issued on January 5 Short Term Limited Duration Insurance Plan rule issued on February 20 (comments deadline April 23)

ACA “Repeal & Replace” – Lessons Learned Never a good idea to do major health care legislation without working with the other party Republicans lack consensus on replacing the ACA While the division between Senators from expansion and non-expansion states contributed to the demise of “repeal & replace,” proposals to impose a Medicaid “per capita cap” did not Will “repeal & replace” return in 2019?

What Comes Next? No more votes on “repeal & replace” are expected before November mid-term elections Bipartisan small group and individual market stabilization legislation in the FY 2018 “Omnibus” Appropriations package? Restoration of CSR subsidies through 2022, Reallocation of funding for outreach and enrollment for 2018, Streamline the 1332 waiver process for states, while maintaining critical protections Initiate a federal reinsurance program for states Trump Administration proposals issued on March 7 Expand short-term duration policies Expand Health Savings Accounts (HSAs) Increase age-related premium band from 3:1 to 5:1

ACA in Pennsylvania All insurers remained in the exchange for 2018; rates increased an average of 30.6%, mostly due to CSR funding elimination (increases were projected to be 7.6% had CSRs been in place for 2018) 2018 exchange enrollment – 389,081 in private plans, down almost 9% from 2017 (due in part to shorter enrollment period in December 2017) – end of enrollment penalty coming in 2019 711,000 enrolled in Medicaid expansion in 2018 https://www.healthinsurance.org/pennsylvania-state-health-insurance-exchange

2-Year Bipartisan Budget Agreement Agreement reached February 7, FY 2018 “Omnibus” spending bill must be completed by March 23 Increases defense and non-defense discretionary spending by nearly $300 billion for the next two years above the current Budget Control Act (BCA) caps and eliminates the threat of an across the board sequester cut Increases in Opioid and Mental Health Funding: Includes $6 billion in additional funding over the next two years to address the opioid epidemic and fund mental health services Funding for the National Institutes of Health (NIH): Includes an additional $2 billion for NIH over the next two years, which could increase funding for the National Institute of Mental Health (NIMH)

2-Year Bipartisan Budget Agreement Extension of Health Care Programs: Extends the Children’s Health Insurance Program (CHIP) for an additional four years through FY 2027 and extends funding for community health centers, which expired at the end of FY 2017, for two years. Permanent Extension of Medicare Special Needs Plans (SNPs), including Dual Eligible SNPs. Repeal of the Independent Payment Advisory Board (IPAB) Accelerate closing the Medicare Part D “Donut Hole” by one year – Concerns about destabilizing the program

Mental Illness Research at NIMH Current FY 2017 funding level - $1.601 billion, up $160 million since FY 2014 FY 2018 President - $1.244 billion FY 2018 House bill - $1.625 billion FY 2018 Senate bill - $1.724 billion BRAIN Initiative - $260 million for FY 2017

Mental Health Services at SAMHSA Mental Health Block Grant currently funded at $563 million, level funding now in both the House and Senate FY 2018 bills Most other programs at SAMHSA are likely to be level funded going forward including: PATH - $56 million Childrens Mental Health - $119 million Primary – Behavioral Health Integration - $49.8 million Mental Health First Aid - $15 million AOT Pilot - $15 million

Supportive Housing at HUD Section 811 currently funded at $146 million – only enough funding to renew existing units Draft FY 2018 House bill includes a $30 million increase for Section 811 “mainstream” housing vouchers, in addition to $10 million in FY 2017 McKinney-Vento Homeless Assistance currently funded at $2.383 billion, draft FY 2018 Senate bill includes a $70 million increase

Mental Health Services and Research at VA House passed FY 2018 bill (HR 2998) funds overall VA health care at $69 billion, including: $8.4 billion in mental health care services (nearly a $1.4 billion increase in two years), $186 million in suicide prevention activities, $316 million for TBI, and $7.3 billion in homeless veterans treatment, services, housing, and job treatment.

Other NAMI Legislative Priorities Behavioral Health Information Technology Act (S 1732 & HR 3331) Protecting Jessica Grubb’s Legacy Act (S 1850) & Overdose Prevention & Safety Act (HR 3545) Reforms 42 CFR Part 2 to allow for harmonization with HIPAA and integration of behavioral health treatment records Control Unlawful Fugitive Felon Act (HR 2792) Passed by the House on September 28 Eliminates eligibility for SSI for anyone with an outstanding warrant or missed court appearance

Other NAMI Legislative Priorities Strengthening Protections for Social Security Beneficiaries Act (HR 4537) Unanimously passed the House February 5, Strengthens the Social Security Representative Payee program FDA Reauthorization Act (HR 2430, now P.L. 115-52) Renews the Prescription Drug User Fee Act, known as PDUFA VI

Take Action & Get NAMI Advocacy Alerts: https://www.nami.org/Get-Involved/Take-Action-on-Advocacy-Issues NAMI 2017 Convention June 27-30 in New Orleans https://www.nami.org/Get-Involved/2018-NAMI-National-Convention Joint National Council-NAMI-MHA Hill Day April 25 in Washington https://natcon18.thenationalcouncil.org/