everybody had insurance coverage. in the individual market, the dynamics are, quite rightly, if there wasn't an under a requirement now to limit folks based on, you know, pre-existing condition or to look at their medical history, you could go in, you know you're going to have some very high-cost medical bills, get insurance coverage for a couple of months and drop it. so you're paying a few hundred dollars in premium. you get hundreds of thousands of dollars in medical costs. and quite rightly, that just doesn't work for me business model to be very blunt about it. . . we

should have mandates, and the others say no. i think everyone has emerged together their ideas. in massachusetts, that plan passed a year and a half ago, they recovered 97% of the people. the question is, will america, will business allow, in a sense, government to say you must have insurance, in the same manner that if you drive a car, you must have insurance for that car. >> if i could jump in really

quickly, the question about mandates is very important, but it misses the underlying issue which is if there is not affordable coverage for you, it is irrelevant. if folks don't get coverage, because of the economics, a mandate is an important component of the overall health care reform package, but again, if we can't address the underlying economics, it doesn't matter what other things we have. we are just not going to get the deal done. >> that leads the group to support having a government auction saying that plan will be less expensive and bring everyone in.

it is the debate. the issue of our country ordering, whatever word we want to use, the 21-year-old young man or young lady who drives a motorcycle, says i don't want to work in the restaurant, i don't want to have coverage and then goes out and has an accident which costs 1 or $2 billion, who pays for that? >> i was just thinking about what tom was saying. if we can get 97%, i will take it. that sounds pretty good. i have a question for these folks, for any of you to pick up on, this question about coverage, something about

coverage, if something happens, that coverage is going to happen. what about the dimension of the delivery system, setting aside the planned parts of it, what do you all think is likely to happen with respect to provisions around service delivery? >> first of all, i never knew -- i never used the word mandate under any scenario. shoot me, i want a mandate. everyone should be demanded to have healthcare, people should purchase health care in the context of shared responsibility in may. at the end of the day, that is what we have to do. we can pretend that we don't. if you have an individual, you have the insurance reforms if

you have an individual retirement. congress has already decided the requirement, let's not have that debate again. at the end of the day if you want to make the system work, you do that. you make it work to get insurance reforms to work, to do prevention well, to make sure people don't get in and out of the system, people go in and out of coverage states, it doesn't happen. let's put coverage aside and make it work. we have to change how we deliver health care and tax credits to make it affordable for people to purchase health care. you do all those things, they come together but the idea that you can do this piece and this peace and this piece separate and apart, it won't work. this is the most important thing

for us to recognize -- having it done is an infrastructure, then we get to the implementation. some of the implementation, 90% of the implementation will be happening post enactment. we won't have legislation in 2009 and see it implemented in 2010. this will be a multi-year implementation which provides the opportunity for all of us in this room to work collaborative with the state, the federal government, the health plans, with others, to get this done right. as part of that, we deal with that, work force and delivery issues, if you cover more people, they will require services. we have to be thoughtful in terms of workforce issues and we think about what we need to have in terms of health personnel. we need a lot more primary care focus and less special fee. that signal will come out of the

congress as well. will it be today or tomorrow? know. the most important thing is these guys are sort of hearing this picture and they are going to mess up. they are in congress. at the end of the day this doesn't happen. this happens maybe once every generation in usually we blow it. if we get it in place, we can fix it. make sure the infrastructure works together. >> changing plans is one of the problems that has been written about, why prevention has always been a challenge in america. people move around. the plan that person is in doesn't want to spend money on

preventive well less. they have done that and a person goes to another planet and spends $10 a month. we have to address that. in europe, as most of us know, they have a 10 to 20 year look and a more robust prevention program, and we have to integrate that into our thinking. the issue of cost you brought up is central. at this panel we are not going to address the issue of where we get $1 trillion or $2 trillion. what can we do, organizations.

whether they are organizational, that was shocking. it looked at the cost of care in texas and all passed though which is 13 miles down the road or something. $30,000 per person except for federal medicare. el patch thome was $75 million. quite remarkable. if we don't address that type of issue, because of defensive medicine and so forth, we should talk about that. >> if you read that article which was very impressive, you find a culture of excess with respect to the provision of care. if the way this is going to go,

once in a generation time when the congress gets it right and the congress gets it white -- right with respect to the aspects that have been discussed, and the time is created for those implementation activities to take place. that becomes the critical time for us to the mental health advocates, not so much now, knock on wood. perry is going to be included. we still have to keep the pressure on with respect to reforms, then that creates a playing field for change. it seems to me the issue of wellness and prevention becomes the sweet spot for the mental health community. these reforms are probably not going to go to critical changes in the high end safety net for the mental health delivery

system that states -- they is operating. we can get to that later. one of the revolutionary aspects of reform we talked about several years ago was trading in the state systems over time for a single approach that would provide coverage to everybody, which was a good thing. maybe we were not quite ready. a conversation about if we do get reform, how do we come in to that conversation with a message about prevention and early intervention? i will come back to the point i was making about the necessity of a mental health person on the team. with what pediatricians do with ad adhd, i am not an expert on this and are no the academy of pediatrics is coming out of the program for all the members about how to do mental health care right, which is an

extraordinary opportunity. my impression is most pediatricians can't get reimbursed, for the time it takes to do a reliable work out of adhd, you needed detailed history from the parents, it takes a minimum of half an hour to go through that, the scales have to be filled out, it is going to be reliable and so on. the kids are getting any treatment at all, half the kids who are getting treatment don't have adhd, and half of them are getting nothing except medication. this is a cup that is half full and half-empty. the conversation of how to do that is a critical conversation for all of us, and may be the focus of next year's conversation when we are thinking about how do we have an impact on the reforms that have

been enacted. >> i want to make a couple points about cost. it is the underlying issue that needs to be addressed. my first point was made by somebody in the audience. i sat through the first session and someone got up and said it is not saving money, it is spending money smarter. it is not a matter of me saying to a provider i gave you $100 yesterday, $68 today, it is really i gave you $100 yesterday, i will give you $100 today. if we can have measurable improvements in your patient population. sometimes when we say we will address costs, the most immediate thing is we are going toslash the budget.

we need to look at doing things smarter and more efficiently, administratively. there are a lot of things that health plans do, to drive the community in seen in terms of dealing with claims and administrative problems. we need to deal with that. as taxpayers, we have to recognize, the solution is not going to be cheap. there has to be a willingness to dedicate more resources. employers understand at as well. one of the great things about what massachusetts did, whether you agree with the model they set up, what is the role of the individual, the role of government, the role of the employer, and what can they contribute to the solution? in terms of cost, it is not

saving money, it is spending it smarter. we have to recognize that we all have a piece of that that we are going to be responsible for. >> personal responsibility is going to be part of the whole thing for all of us, and we are going to have to give up something, be part of a solution. one of the issues, when we really get health reform, the reality is we are going to change the way physicians are trained, the way nurses are trained, the way social workers are trained, training today is today, pretty much what it was when we went to school several years ago. the mail clinic -- the mayo clinic has a model that works. physicians and the staff, they

do exactly what mike said, everyone is together, physicians and employees. you get into the system for care, the system makes sure that you get your eyes, your ears in mental health and nobody has gone another way. it is going to take a change and will not occur tomorrow. will be a 10 years change. as long as we continue to do medicine on a piecemeal basis for your basically paying people to do a particular task, it is going to be hard to get those costs down. >> i try to line this in my budget testimony, you can pay me now or pay me later, which i thought was pretty good. when you think about the problems of untreated mental illness, we have these

conditions. before you can enter care, just to know that 40% of the people coming into ss i have a mental illness. and these people who have a job as well as health-care, they wouldn't have to be on ssi, to be fearful of going back to work and losing the benefits, this message of wellness and prevention, which is so critical to the whole history of mha, this is something that is going to come into focus, that the public is looking for, is really a hopeful sign. >> i would like to open it up for a few questions. we can't do many but we can do a

few. yes? >> how do you see the system controlling abuse? as soon as they say mental health is covered, the beautiful woodlands' opening up again. $75,000 a week of alcoholic drug treatments, how will they be able to monitor the system? >> it does seem to me, we have seen the response to that emerge to some extent, coverage for these conditions had improved over the years. every time and every place, we have seen legislation. what we are seeing, insurers go to some approach to managed care. the smart approach to managing

care, with the mainstream plan or whether it is a specialty organization like dr. volk runs, they all encourage access to a little care at the beginning and bailout of attention to 2 things, who are the providers who tend to practice in a way that looks reasonably effective and efficient? not by micromanaging them butting urging those people who participate in the network and number 2, look seriously at the use of and the costs of high end care. without cutting that too much, to look in particular for opportunities where maybe somebody can be home and go to a partial hospital program a few days a week. i think the market place has responded to increases in mental

health coverage by turning to management. i haven't always got that right. there are some circumstancess where we managed it too much and one of the things we have to get smarter about in this environment, what should be the obligation for plans with respect to these conditions. it is easy to depress care. the marketplace has responded. this is hopefully part of the dialogue we have next year post federal action, how do we do this smart? >> i don't want to send the message for you not to get integrated in the debate in

certain areas. to build on what you said, on the prevention primary-care infrastructure, and coverage, one might argue we should have some investment in the early years even before coverage takes place. some would argue, it is fair to say that having insurance doesn't necessarily mean you have a place to go to access coverage. the whole issue of community health centers, the issue of the childless adults low income population, the health plans are not used to covering that population, saying you do medicaid under contract with certain populations, that is your population. the childless adults could need health care. huge populations of mentally ill people who need special care,

special fop process about how if this infusion of folks are coming in to get care, how do we do that? i just want to say there are some early year issues and visions, that affect the policy, in your broader vision of where your going, you need to be active, as well as, in particular, follow up on the implementation. the last issue, is this going to be a vision weather is a state or local significant role in these exchanges and how that works and inter relates to your relationships to state and local level are very important. before i stopped talking, i wanted to plant those seeds. >> i am sorry. >> i have a question. when you mentioned anything we are working on right now would not happen for the next 2 years,

why is it that the mental health area takes steps that are enrolled and we have a big force of numbers of people, why should we have to settle for something over 10 to 15 periods and by the time this shows it, we have the lowest amount of people here in mental health america, it has been around for 100 years, why should we take the steps and be put back on the back burner for other things? >> a really good question. i want to go back to several of the panelists to say that is not -- i really appreciate -- the message of wellness and prevention is now. that has been our assignment with respect to this change, but also to your point, in the ninety ninth year of mental health america, parity did pass,

so we can take credit for it not because it was an achievement because it set a benchmark for future reform. i am not sure we can just assume that is going to be included in any plan that my colleagues would agree they would have mental health parity. that is not part of the debate. >> what issues might you have on that? >> i know from labor perspective, i was with the afl-cio, we opposed it initially. when it came to the reauthorization we had other plans sponsors, plan sponsors who think of things in a more traditional role to cover another benefit. when it came time to reauthorize it, you had made the case that

we need to do this. this is not just thinking about adding to my benefit package and an additional cost for a longer-term savings. >> we can take one more question. [applause] >> this is a cautionary piece from our perspective in new york we have very good mental health parity mottos, timothy's law has been a great bill, we were unable to get family health plus medicaid programs as part of the benefit. as a cautionary peace, i agree with the commissioner, we have to have somebody on the inside in the sense that i think they are going to take a lot of advocacy on our part to make sure that mental health does become part of the broader discussion about mental health

benefit packages, because i think it makes us very concerned, we really need to not say that this is a done deal and we have a lot of advocacy to make this happen. i have seen our issues in new york. >> if i could briefly respond en, the first step as been made, which is there is broad agreement and recognition on everybody's part that addressing the issues of the mentally ill has got to be part of the package. there is no longer an assumption that mental health is somehow over there. it is a trite phrase that the devil is in the details. when we get health care reform this year, you can't give up the fight. you have to go to the next step, to focus on how do you carry that out in a way that is most

effective for your communities. my parting word to all of you is keep fighting for health-care reform, but don't assume if the president signs that bill that you can pack up and go home, you need to keep pushing. >> can i say one thing about the opportunity here, the definition of the benefit package, there is broad recognition that folks don't want to go through a process to legislate in statutes exactly what the benefits are. what will be the process for determining that if it is not written into statute? that is one end of the spectrum, pick a dollar amount that we can afford and let someone else figure out what fits into that package. for big categories of benefits that are covered with that dollar amount, there's the kennedy draft which says we can

establish a medical advisory council of experts to determine based on evidence, what should be a package to help people get healthy and help them get well when they're sick. the final option is our best hope. when you look through the lens of evidence instead of politics, we feel more comfortable with the benefits package. the discussion is how do we bake in more consumer patience? how do we make it transparent? and insulated from politics, the experts make recommendations on this point, if this is a process we can load off now, opportunities for engaging that process, we are at the table when it kicks off. >> you brought us to our conclusion. i want to thank mental health america, extremely helpful.

i will leave you with this. please do not leave mental health coverage to someone else. it is all about responsibility. you are all leaders in your communities, you are leaders in your neighborhoods, your states, your cities, you have audiences that you have to mobilize, whether it is congress, senate, state legislatures, governors, whoever it is, it is our responsibility to make sure we follow through on mental health coverage. thank you all very much, and thank the panel very much. [applause] byron ..