think we understand and the general medical settings, unless there is a mental health specialists on the team or on the floor it will not get down. around 44% of gp say they are comfortable with treating depression. if we look at our collison, that drops below 20%. what of the things this well we look at a specialist across the street but in the pediatrician's office and the chronic disease program [applause] in this context it clearly is true parity is a great place to start a we have to understand when it comes to prevention and treatment it is insufficient. it is illegal or theoretical access to a benefit that most

people don't use because the condition has not been identified. >> we should spend some time talking about expanding your interest in a well this and prevention, the recovery movement is central to what we're doing and i know the afl-cio has always been very interested. huge domain and would be supportive of the month -- supportive of us continuing what we have been doing fell last many years. >> of course. following on this there are a number of opportunities, a chronic care focus, but also a lot of discussion about medical halls and looking holistic eight -- and the center care come it may not be the mental health person in the pediatrician's office but ready access not screening

properly or make sure they see someone is tracking the spread of the pediatricians office is a model in that regard. there are a lot of opportunities to integrate this with the achievements in that area. >> on a particularly personal notes, in massachusetts we have run a program there for many years, 15 years, they took day segment high utilize hours of mental illness and high cost, a physical and mental and carved them out to now new york state has followed with a program that just started a few weeks ago. basically integrating the mental health, physical health and all of the social services, new york is now a leader in that the tests i know what you will find is the cost will go down, the

consumer will get better care, and you will have a system which cost less and people in improve. it is very good you bring that up because that is happening right now and as we get more data on it, it will be fascinating to watch and happen. tom, i want to talk to you about mandates. not a small topic. obviously when we talk about mandates, from our perspective there is too levels, mandating that the insurance company is excepts day six ups consumers irregardless of pre-existing condition then have a discussion on mandating coverage for all americans. >> we would agree if you want

to get insurance, you should have it and there should not be any pre-existing condition, there should be a guarantee issue but from our standpoint the most important component is the individual mandate that everybody have coverage. in the individual market, and the dynamics quite frankly if there was not a requirement now to limit folks based on pre-existing condition or look at their medical history, you could go and become what you know, you will have very high-cost medical bills, gets insurance coverage for a couple of months then drop it for a couple hundred dollars a premium you get hundreds of thousands of medical costs that does not work for a business model to be blunt. but we are committed to reforming the insurance market and having requirements that if you want insurance, you

will get it, there will not be limits put on what you will get and if you can't afford it, you will get help to pay for that. >> how do we feel as a panel america will feel? it was obviously a big issue in the campaign. we have two candidates one is saying we should have mandates and the other, saying no. i think everyone has emerged to gather with their ideas and massachusetts that plan past year and a half ago they have covered about 97% of the people. the question is will ameritech, will business allow it in a sense, government to say you must have health insurance in the same manner that if you drive a car, you

must have insurance for that car? it will be a huge issue. >> if i can jump and quickly, i think the question about mandates is very important but i think sometimes if mrs. the underlying issue that if there is not affordable coverage of their four you requiring you too have coverage is irrelevant. even in massachusetts is a cohort two cannot get coverage because of the economics. i think a mandate is an important component of the overall health care reform package. but again come if we cannot address the underlying economics it does not really matter what other kinds of things we have. we will not get the deal done. >> writes. right. that leads the group who

supports having a government auction saying that plan will be less expensive and therefore bring everyone in. it is a debate obviously. but the issue of having our country's ordering, whatever the word, every 21 year-old, a young man or young lady that drives a motorcycle says i don't want to have coverage then has an accident which cost one or $2 million and other question is, of who pays for that? >> i was just thinking what tom was saying and sitting here right now, if we could get 97%, i would take at. [laughter] that sounds pretty good. if i can come i have a question for these folks.

myself which for any of you, other question about coverage, we think coverage is if something happens if given the caveat that will happen. what about the dimension of the service delivery system? setting aside the planned parts of it, what do think is likely to happen with respect to provisions around service delivery? >> first of all, i never use the word mandate under any scenario. [laughter] because shoots me. i want a mandate. [laughter] the difference between saying everyone to have -- be mandated to have healthcare people should purchase health care in the context of shared responsibility is night and

day but at the end of the day, that is what we have to do. we can pretend we don't. you only get 97% with individual but only the reform with the individual. the congress has already decided it is a requirement so let's not have that debate again. we had that. at the end of the day to make the system more, you do that and make it work to get insurance reforms were, i do prevention confront make sure people are not going in and out of the system how do chronic coverage? it does not have been so put it aside and make it work. how do you make it work? you have to constrain costs and change how we deliver health care, provide tax credits and subsidies to make it affordable, pay for its, if you do all of these things it

comes together. but the adr that you can do this piece in this piece and this piece separate and apart will work. this is the most important thing for us to recognize. secondly, having it done in ast infrastructure then we get to the implementation. in fact, 90% of the implementation will be happening post enactment. we will not pass legislation been in 2009 and is see it implemented 2010. this will be a multi-year implementation which provides the opportunity for all of this in this room to work collaborative with the states, a federal government, health plan, others come much to get it done right. as part of that you have to deal with workforce and delivery copper curfew cover more people more people will come and require services that means you have to be

thoughtful of workforce issues and what do we need with health personnel? a lot more primary health and a lot less special less. that will come out of the congress as well. will it be today this, tomorrow that? no. but they are hearing the whole picture nashville and look, they will mess up. it is congress. [laughter] but don't ever let days at the end of the day this does not happen. maybe once every generation and usually be below lipper grip we get it in place, we can fix it just make sure the overall infrastructure works together. >> one of the issues you brought up and i am changing plans is one of the problems that has been written about and why prevention always has

been a challenge in america because people move around and the planet that a person it is in doesn't want to spend the money on prevention and because then they have done that and then the person close to another plan that saves five for $10,000 per month. as most of us know, they have a 10 or 20 year look ahead with a more robust prevention program and i think we have to integrate that into our thinking. the issue of cost is essential for. we will not address the issue where do we get one or $2 trillion for its because mike said he will arrange for that. [laughter] but the issue of organizations

come individual responsibility or organizational responsibility, the recent article in "the new yorker" which stated which is shocking of the cost of care and make dollars in taxes and el paso 30 miles down the road it was $50,000 per person under federal medicaid and el paso was $7,500 per person in. so quite remarkable. if we don't address that type of issue then the question is why is that? because of malpractice insurance, over testing, kinds of medicine but i think we should talk about that. >> if you read that article is

a culture of the excess with respect to the provision of care. i have been thinking if the way this willow go in this once in a generation time where congress gets it right with respect to the broad aspect of reform that have been discussed, and then the time created for those implementation activities it to take place, that becomes the critical time for those of us were mental-health advocates come and knock on wood, but we will have reform and parity will be included, but we think. so to keep a fresh eye on reform but that creates a playing field for change. then it seems the message of wellness and prevention becomes, in a sense come a sweet spot for the mental-health community. these reforms will not go to

critical changes in the high end safety net for example, that the mental health delivery system that states operate. maybe we can get to that later maybe the revolutionary aspect of health reform 15 years ago was trading in the state system over time for a single approach to provide care to everybody, which was a good thing. but maybe we were not quite ready for that but a conversation if we do care reform, how do we come into that conversation with a message about prevention and early intervention? to come back to the point* of necessity of a mental health person on the team with respect to what pediatricians do with a ph.d., i am not an expert in this, the american academy of pediatrics is coming out with a program for

all of the members about how to do mental-health care right in pediatric practices which is an extraordinary opportunity my eighth impression is pediatricians cannot get reimbursed for the time that it takes to do a reliable work up of eight ph.d. -- adhd it takes a minimum half-hour to go through that and there are scales, reliable and what we see is advocates with adhd are getting any treatment and half the kids and get treatment don't have a and virtually none of the kids are getting anything except medication. so this is a cup half full and half empty so the conversation about how to do the right is a

critical conversation for all of the us and probably are may be the focus of next year's conversation when we say how do we have been impacted now on reforms enacted? vermette dae want to make a couple of points about cost because i agree it is the underlying issue my first point* was made by somebody in the audience. i sat through the first session and somebody said it is not saving money but spending money smarter. it is not a matter of me saying to a provider i gave the $100 yesterday i will give $68 today i did is i gave you $100 yesterday and 100 today if we can have measurable improvement in the patient population for growth i think when we say we will address cost the immediate thing is we will slash the budget and that will take care of it.

the second issue that we need to be very clear about, everybody has got to contribute to that from the health plan side, we need to look at doing things smarter and more efficiently and administratively, there is a lot of things for example, that helps plants do that drive the community insane in doing with claims and administrative problems, we'd need to do with at as taxpayers, we have to recognize this solution is not cheap. there has to be a willingness to dedicate more resources for employers understand that as well. whine of a great things about what massachusetts did become aware the agree with the model they sat down and said, what

is the role of the individual of government or the employer cracks what can they contribute to the solution? in terms of cost, it is not saving money but spending smarter and we have to recognize we have a piece of that we will be responsible for. >> personal responsibility is part of the whole thing for all of us. we will have to give up something or me part of a solution. one of the issues, but when we really gets health reform, the reality is we will change physicians are trained, induced -- nurses are trained because trading today is pretty much what it was when we went to school several years ago. the reality is the mayo clinic

has a model that works. basically physicians and all of the staff know exactly, everyone together physicians and others are employees, the system manages you get into the system for care than it makes sure you get eyes and ears and nose and mental health and nobody has incentives and the other way. it will not occur tomorrow, it will be a 10 year change but as long as we do madison on a piecemeal basis were you pay people to do a particular task it will be hard to get the cost down. >> i tried in my budget just money this year is you can pay me now or you can pay me later

which i thought was pretty gut. [laughter] when you think about the problems of countries did mental illness behalf conditions that are not good for you or your brain and they get worse before you can enter care. and to know 40% of the people on ssi, have a mental illness and a lot of these are folks with the right kind of support, particularly with a job as well as health care, they would not have to be on ssi for the rest of their lives, fearful of going back to work because they'll lose healthcare and benefits. the message of wellness and prevention in which is so critical to the whole history of mhj -- mha what the public

is looking for with reform is a hopeful sign. >> i would like to open it up for a few questions. we cannot do many, but a few. >> i just want to ask, how do you see the system controlling abuse? as soon as they say mental health is recovered all of the beautiful places will open it charging $75,000 for a weekend of drug treatment how can they monitor the system? >> it does seem to me we have seen the response to that emerge to some extent as coverage for these conditions have improved over the years. every time and every place we have seen a state act -- enact

parity legislation we see insurers go to some approach of managed care and a smart approaches have a specialty focus within a mainstream plan or the organization of like dr. dozoretz runs and all organizations that manage it smart come encourage access to a little care and the beginning then pay a lot of attention to who are the providers that attend a practice that looks efficient? not by micromanaging but encouraging those to participate in the network and to look seriously at the use of and cost of high end care and without cutting fat too much to look in particular for opportunities or maybe someone can go to a a partial program a few days per week so they

could turn the corner without going into a hospital. i think the market place has responded to increases of mental health coverage by turning fifth to management. we don't always have that right because there are some circumstances that are managed to match and it is one of the things to get smarter about. and this environment what should be the obligations of plans with respect to these conditions? its reno it is easy to depress care and as as you indicated also if you don't pay attention to spend way too much money on of the wrong thing. this is an area to where the marketplace has responded but this has to be part of the dialogue post federal action how do we do this smart? >> i don't want to send a

message for you not to get integrated in the debate now in certain areas. to build on what you said it is on the prevention primary-care infrastructure, with coverage one may argue we should have investment in the early years even before coverage takes place. certainly it is fair to say having insurance does not necessarily mean you have a place to go to access coverage. the whole issue of community health centers, the childless adults 100% of poverty, the health plans are not used to covering that population and saying, you do it medicaid with certain populations under contract.

that is your population the childless adults, a huge populations of mentally ill people who need special care, a special fund process if this infusion is coming in how do we do without? i just want to say there are some early year issues and visions that both affect policy and broader vision where you're going but you need to be active and and as well as in particular then follow-up on implementation. the last issue, it will this be a phase-in where is state and local significant or a federal role in these exchanges and how that works and enter relates to your relationship is very important. before i stop talking i want to plant those seeds.

>> you mentioned anything we're working right now would not happen in the next year or two so why is it the mental-health period it takes a step title role when we have a big force of numbers of people so why should we have to something for to happen over 10 or 15 periods by year we have a large amount of people and mental health america hasn't been a big advocate so why should we take this step child for all to be put back on the back burner for other things? >> a good question. to go back to several of the panelists, that is not the message. chris, i appreciate your message come months the message of well this and prevention is now part of that

is our assignment with respect to this change r&d 99th year of mental health america to go back to what pointed out, parity did pass, legislation did pass. so this organization and other advocates can feel very proud of and take credit for that now because it was an achievement but it set a benchmark for future reform. i am not sure we can just assume that will be included in any plan but i think my colleagues would agree they will have mental-health parity, that is not part of the debate? >> i know from labor perspective i was not at the afl-cio when it first passed i think we'll posted initially but when it came from reauthorization we were having

plan sponsors that take of traditional insurance for all and what role it cost me and when it came to reauthorize it, it was not a question. you made that case for why we need to do the sparc and not just thinking what is this adding to my benefit package it made sense for a savings come a worker productivity and it made it very clear. >> [applause] >> this is a cautionary piece from our perspective in new york where we have a very good mental health parity law, the timothy's bill but what happened is we were unable to get a family health plus and child health plus as part of that benefit but as a cautionary peace, i did agree with the commissioner we have to have somebody on the inside