Memorandum I- Part 3 of 3. Responses of Am Psychiatric Association, Am. Psychological Association and AP Practice Organization

VELANDY MANOHAR, M.D.,

Distinguished Life Fellow APA

Steering committee member- Psychotherapy Caucus of the Am. Psychiatric Association

Steering Committee member- National Physicians Alliance in CT

93, Meeting House Road , Haddam, CT 06438

01 14 17

Memorandum I- Part 3 of 3

The key principles that I hold pre-eminent in my day to day life as a physician, as a neighbor and member of the community that nurtures my family and me.

In lumine- Tuo Videbimus Lumen Psalm 36.9 In Thy light shall we see light KJV

Therefore all things whatsoever ye would that men should do to you, do ye even so to them: for this is the law and the prophets. St. Matthew 7:12 KJV

Primum Non Nocere- Hippocrates. Above all-do no harm

“Enable Noble thoughts come to you from all sides” Rk Veda, I-89-1 Sanatana Dharma.

Dear and Respected Sen.,

I would like to place respectfully before you Sir three key documents that can be instructive and helpful in shedding light on our path forward to reform health care access, elimination of disparities, financing mechanisms, structure, processes and outcomes thus striving to achieve the Quadruple AIM[ The Triple Aim plus the important goal of Managing the forces that induce and exacerbate the burnout phenomenon which is adversely impacting the Manpower resources essential to achieving the Triple AIM..

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”: I welcome your responses and am willing to be of assistance as you see fit.

? Improving the patient experience of care (including quality[Added Value to Person’s life] and satisfaction);

? Improving the health of populations; and

? Reducing the per capita cost of health care

The information I wish to share respectfully with you builds on the foundational materials I sent you in Parts 1 and 2 for instance in attachment I, I offer a Report on the Oregon Plan which appears to be serving the people of Oregon quite well in terms of achieving the components of the Triple Aim. This plan could be considered as an alternative model for a fifty state role out.

I. The Oregon Plan: Oregon’s home-grown health care transformation, as well as our Medicaid waiver, is why we can have a healthier population for less money. “Our story is particularly important as Congress and President-elect Trump turn up the volume about repealing President Obama’s signature health law and making substantial changes to the Medicaid program. To build a better health system, we need to succeed in making Americans healthier while also keeping health care affordable. This is where Oregon stands out. Medicaid waivers have always given states the flexibility to deliver the program in innovative ways. Coordinated care organizations, like Health Share of Oregon, formed as part of a 2012 waiver, are Oregon’s latest innovation. .. Coordinated care organizations are a true public/private solution getting real results. They bridge the gaps within America’s complicated, fragmented health care system so our members get the care they need, when they need it, with a strong emphasis on prevention. Our role encompasses everything from building a data sharing system for health providers, to creating a regional mental health system, to strengthening 911 services. We are held accountable to the State, as well as Oregonians, through outcome-oriented quality measures and financial rules capping our per-member annual cost growth.

II. The Response of the Am Psychiatric Association to the perils of Repeal of the PPA ACA because of the expected adverse impact on persons with medical Illness due to potential loss of hard-fought gains we have made in establishing parity for treatment of MH disorders in the USA in the past 5 -6 years. “On behalf of the American Psychiatric Association (APA), the national medical specialty association representing over 36,500 psychiatric physicians nationwide, we urge you to support continued and expanded access to quality evidence-based mental health care services. Mental illness is very prevalent in the United States. According to the National Institute of Mental Health, over 68 million Americans experienced a psychiatric or substance use disorder in the past year. That is over 20 percent of the nation’s population. other mental health issues previously struggled to obtain insurance coverage to help them access care. Current law changed that by requiring coverage of necessary services to treat mental illness. Consequently, it has become less burdensome for Americans to access appropriate and evidence-based mental health care, thus improving their chance for healthier and more productive lives while reducing the stigma around mental illness. As Congress considers significant reforms to health insurance coverage this year, it is critical that any such reforms do not undo the gains which have been made over the past several years for individuals with mental illness, and that any such reforms only further enhance coverage and access to lifesaving evidence-based care.

III. A. . The American Psychological Association and its affiliated APA Practice Organization have called on congressional leaders not to repeal the Affordable Care Act without simultaneously replacing it with legislation to ensure that all Americans have insurance coverage with access to comprehensive mental health care at parity with physical health services. The two organizations also sent President-elect Donald J. Trump their recommendations for ensuring health care reform policies meet the treatment needs of Americans with mental and substance use disorders. A letter from the organizations (PDF, 71KB) to House Speaker Paul Ryan, R-Wis., and Sen. Majority Leader Mitch McConnell R-Ky., acknowledged that while the Affordable Care Act could be improved, it has extended insurance coverage to more than 22 million Americans. “Health insurance is a life-or-death issue,” the letter stated. “It is not the time to repeal the ACA when more Americans with mental disorders are found in prisons, jails and on the streets than in treatment facilities, and when more Americans are dying of drug overdoses than any other form of accidental death.” In a letter to the incoming Trump administration (PDF, 91KB), the organizations spelled out their recommendations for ensuring health care reform policies meet the treatment needs of Americans with mental and substance use disorders. Before the Mental Health Parity and Addiction Equity Act of 2008, they noted, health plans routinely discriminated against people with mental disorders by structuring and applying policies in ways that made it more difficult to access coverage for mental health care than for general medical care. “Even today, private sector health plans deny coverage for mental health services twice as often as coverage for general medical care,” the letter stated. “As a result, individuals with mental disorders rely heavily on public health programs” such as Medicaid, which accounts for an estimated 29 percent of total U.S. mental health spending Medicare and other federal programs account for roughly 20 percent more. Overall, APA and the APA Practice Organization emphasized six core objectives for health care reform: Establish universal access to essential health care services that include mental health and substance use disorder services at parity with physical health services. Establish and enforce health insurance protections for consumers and providers. Integrate mental and behavioral health services into primary-care and other health care services. Ensure access to preventive services, including mental and behavioral health promotion. Expand federal investments in the mental health workforce. Increase federal funding for basic and translational psychological and behavioral research and training. APA and the APA Practice Organization concluded their letters with an expression of interest in working with the new Congress and the Trump administration on health care and other issues of national importance. The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States. APA's membership includes more than 117,500 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance the creation, communication and application of psychological knowledge to benefit society and improve people's lives.

IV. A. After more than six years of this landmark law, let’s look back at the progress we’ve made “ For years, Natoma did everything right. She bought health insurance and paid her premiums on time. But one day, the fear of so many became her reality: She was diagnosed with cancer. She fought for her health and had been living cancer-free for some time, but her insurance company kept raising her insurance rates, year after year. She needed the coverage, but she couldn't afford it. So she had to surrender her health plan and live merely on the hope that she would stay healthy. “ Twenty million Americans have gained health coverage – not counting the 3 million more children gaining coverage during this period of time. More than 90 percent of Americans have health insurance for the first time ever. Up to 129 million people who could have otherwise been denied insurance because of a preexisting condition now have access to coverage – even as we have seen the slowest growth in health care prices in 50 years. And, the quality, coordination, and effectiveness of the health care we receive has improved. Just last year, Natoma wrote another letter. She thanked the President for the Affordable Care Act and told him that she’s remained cancer-free. Her note now joins a collection of letters to the President from people who have been helped by the law. People like Astrid from North Carolina, who was diagnosed with a brain tumor and was able to get the surgery she needed. Or Ann Marie from Connecticut who was able to detect an early stage of breast cancer thanks to better preventive care. You can read these letters and more right here.”

B.  This is in the same Attachment. Both are on White House. Gov.” Improving Health for All Americans; President Obama promised that he would make quality, affordable health care not a privilege, but a right. After nearly 100 years of talk, and decades of trying by presidents of both parties, that's exactly what he did. Today, 20 million more adults gained access to health coverage. We've driven the uninsured rate below 10 percent — the lowest level since we started keeping records — and built stronger, healthier communities through advancements in public health, science, and innovation.”6 domains of . 1Improved Access to Care-23 links to succinct packets of information. 2.Made Health Care and Coverage More Affordable-10 Data Links 3.Improved Accountability, Efficiency, and Quality of Care- 12 Data links. 4. Addressed the Prescription Opioid and Heroin Epidemic- 11 Data links 5.Increased Access to Mental Health Services- 7 Data Links.6. Strengthened Nutrition Standards and Promoted Healthy Living 19 Data Links. Total 87 Data packed Links that is very instructive are available on line ta White House.Gov Web site. President Obama’s health care policies have even broader and more transformative implications for the U.S. economy. In the years to come, the ability to buy portable and affordable plans on a competitive marketplace will allow countless Americans to move, start businesses, and dream big American dreams – without worrying if an illness will bankrupt them- There are heart-warming letters from individuals like Natoma that attest to these assertions. 

V.          Senate passes Senate Republicans Take the First Big Step Toward Repealing Obamacare: Senate Republicans have taken the first big step toward repealing Obamacare, setting in motion a legislative process that could undo the largest expansion of government in a generation and leave more than 20 million Americans without health insurance. Passing this resolution is a critical first step in rescinding Obamacare because it would allow Congress to consider legislation through the budget “reconciliation” process, with its special rules that make it impossible for Democrats to block action in the Senate by wielding the filibuster. [This is the most dangerous part of the whole process. That is why we must strengthen the hands of the 9 senators who are opposed repeal without replacement. And the Members of Congress who also oppose repeal without offering prudent and sustainable replacement HC financing package which will include provisions to allow competitive bidding from vendors of Medical products and service to Medicare recipients and manage the pricing strategies of Drug products both newly approved and especially generic drugs the cost to insurance companies and consumers have been raised several fold even after the Pharmaceutical companies who brought these to market were allowed to charge whatever price the market would bear during the years they had full patent protection to recoup the cost of discovering and developing the drug.VM]

I think when we repeal Obamacare we need to have the solution in place moving forward," the Arkansas Republican told MSNBC's Chuck Todd Thursday. "I don't think we can just repeal Obamacare and say we're going to get the answer two years from now. This is a very complicated problem. "Trump himself has also spoken in favor of immediate replacement -- though it's unclear if he was referring to when the replacement would take effect or when it should be passed. As insurance providers have already set their policies for the coming year, the repeal would not affect Americans this year regardless of when it was passed. "No, we're going to do it simultaneously. It'll be just fine," Trump told CBS' "60 Minutes" in November when asked if there would be any gap in coverage. "We're not going to have, like, a two-day period and we're not going to have a two-year period where there's nothing. It will be repealed and replaced."

VI. The Hartford Courant story reflects the opinions in my state. It speaks also about a letter sent by Governor Malloy and detailed letter sent by Insurance Commissioner Katherine Ward. Insurance Commissioner Katharine Wade wrote to McCarthy that since 2011, Connecticut's uninsured rate has gone from 8 percent to a historic low of 3 percent. About 110,000 residents have gotten coverage through the state's health care exchange and the expansion of Medicaid has provided coverage to more than 200,000 Connecticut residents. "Rather than repeal the law, Congress should improve it," she wrote. "There are three areas that we can focus on to improve going forward – 

1. market stability, 

2.The regulatory environment and state flexibility,[Emphasized by Oregon State Medicare Waiver Health Care plan.VM]

3.Cost containment." Commissioner Katherine Ward. The governors and Commissioner Wards letters were sent to your good self . These letters were in response to a request from congressional Republicans to state leaders for input about health care reform. “I totally endorse the recommendations especially the part about cost containment. That is part of the Triple Aim and the State of Oregon a Medicaid Waiver State has demonstrated how to build a better Health Care System- To build a better health system, we need to succeed in making Americans healthier while also keeping health care affordable. VM]

        VII. I am attaching the petition you [Rep.E. Esty] sent me. I have signed already.

I welcome your responses. . 

At the end of this petition [Part 3] to urge you to please act judiciously [ and additionally encourage your peers as you see fit] as you address Health Care reform I offer this prayer with all humility and gratitude for the beneficence I have been blessed with and wellbeing made possible by the generosity of the American Nation by the people who took me in and made feel like I belonged here among all the people I encountered without exception. I am a first generation American. “…I was a stranger and you welcomed me…St. Matthew 25:35

“When we do the best that we can, we never know what miracle is wrought in our life, or in the life of another. “ Ms. Helen Keller 

“The marvelous richness of human experience would lose something of rewarding joy if there were NO Limitations to overcome. “ Ms. Helen Keller

Touch stones of Spiritual Wisdom:

Martin Luther- Christmas Sermon 1543

“The Inn was full…

There are many of you who think to yourselves: If only I had been there! [We are here now-What are we going to do? Let us reason together

How quick I would have been to help the baby!”

Why don’t you do it now? You have Christ in your neighbor. You ought to serve your neighbor, for what you do to your neighbor in need, you do to the Lord Christ Himself.”

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Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. 25:40 KJV

Therefore, all things whatsoever ye would that men should do to you, do ye even so to them: for this is the law and the prophets. KJV

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Civilization must be judged and prized, not by the amount of power it has developed, but by how much it has evolved and given expression to, by its laws and institutions, the love of humanity. Rabindranath Tagore

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Lokah samastha Sukhino Bhavantu. [Sanatana Dharma- Hinduism]

May all human beings be blessed with happiness

I am a first generation Naturalized American grateful to those who nurtured my family and I in many parts of the USA. I am reminded of this statement-“ I was a stranger and ye took me.in” Matthew 25:35 KJV.

I am a proud father of a son who served in the USMC, humbled by the glorious service of our active duty service members and veterans in defense of our Country. We, my son and I have slowly walked our way through the section where the honored dead of OIF and OEF campaigns are interred with honor and sent message and photographs to the next of kin of some of the heroic Marines interred there. I want to make sure I pay my homage and express my gratitude by doing what I can with my aptitude, training and my underlying values that sustain my commitment to Equal Justice under the Law and E-Pluribus Unum.- “One from many” We are our brother’s keeper. I believe we Americans are members of one family. Additionally we Americans belong to the Human Family living on all the continents on God’s good Earth.

I cherish this precept and am committed to act in harmony with this teaching; 

“And as ye would that men should do to you, do ye also to them likewise. St. Luke 6:31 KJV

‘Common be your prayer, common be your ends, common be your purpose, Common be your deliberations, Common be your desires, Unified be your hearts, Unified be your hearts, United be your intentions, Perfect be the Union amongst you. Rk Veda X,191-3,4. Sanatana Dharma

Om Shanti, Shanti, Shantihi. [Sanatana Dharma- Hinduism]

May Peace prevail in three domains. [Air, Land and the Waters-also Body, Mind and Soul]

I welcome your responses and am willing to be of assistance as you see fit.

Velandy Manohar, MD.,

Distinguished Life Fellow- Am. Psychiatric Association.

CERTIFIED IN ADMINISTRATIVE PSYCHIATRY [APA]

CERTIFIED BY ABPN: ADDED QUALIFICATION IN ADDICTION PSYCHIATRY

CERTIFIED BY ABPN: PSYCHIATRY 

BOARD CERTIFIED –ABPN-PSYCHOSOMATIC MEDICINE