Medicaid cuts in health bill threaten mental health care for Floridians

June 30--Before Haylee Kalick signed up for Medicaid in 2015, she had been involuntarily committed to hospital psychiatric wards under Florida's Baker Act close to 20 times, said her father, Bruce Kalick. He was the one who had to call police when his daughter swallowed a bottle of pills and when she cut her wrists with a knife.

But ever since Haylee Kalick signed up for Medicaid, the public health insurance program for low-income and disabled Americans, she has been able to receive the multiple prescription drugs, weekly counseling sessions and monthly psychiatric therapy necessary to manage conditions that include Tourette Syndrome, bipolar disorder and obsessive compulsive disorder.

"Medicaid literally saved her life," Bruce Kalick said.

Now, he fears that his daughter's recovery could be short-circuited by Congress' efforts to repeal and replace the Affordable Care Act, also known as Obamacare.

Bills in the House and Senate propose deep cuts to Medicaid funding -- cuts that could reduce or eliminate the mental health services that Haylee Kalick relies on to keep her from spiraling back into a pattern of blackouts, attempts at suicide, and involuntary commitments in psychiatric institutions.

"She's so afraid of going in those places," Kalick said of the psychiatric hospitals where his daughter has been committed. "She comes out worse."

These days, Haylee Kalick, 21, no longer thinks of taking her own life, or of hurting others. And she can envision herself as a wife and mother, with a career.

"I see a future where I'm married and have kids, and I can lead a normal life, a happy life," she said, as she reclined in an easy chair in the den of her grandparents' apartment in Weston. "I want to be happy."

Like Haylee, more than 350,000 Floridians relied on Medicaid for behavioral health services, which includes mental health and substance abuse treatment, in 2015 and 2016 at a cost of about $400 million, according to the state's Agency for Health Care Administration.

That ranks Florida's Medicaid program near the bottom of all states in behavioral health spending, said Anne Swerlick, an attorney and analyst for the Florida Policy Institute, a nonprofit that examines state policy impacts on the economy.

Because Florida ranks low in spending for Medicaid in general, an average of $5,864 per enrolled person, Swerlick said state legislators could be forced to make drastic cuts to the program under the proposal passed by the U.S. House of Representatives, called the American Health Care Act, and the bill currently in the Senate, known as the Better Care Reconciliation Act.

Both bills call for spending limits -- known as "per capita caps" -- for each person enrolled in Medicaid, with annual adjustments for medical inflation. Caps would be calculated based on each state's historical Medicaid expenditures, and any amount spent above the cap would be entirely at the state's expense.

"This would make a bad situation worse," Swerlick said.

Under its current structure, Medicaid spending is unlimited, with the federal government providing 61 cents of every dollar that Florida spends to fund the program.

Swerlick said that under a Medicaid spending cap, mental health is likely to be targeted for budget cuts because it's considered an optional benefit for adults under federal Medicaid rules. Federal law makes certain medical care mandatory under Medicaid, such as hospitalization and nursing home coverage.

The mandatory benefits would remain in place under the House and Senate bills because Republicans in Congress are pursuing changes to the Affordable Care Act under a budget reconciliation measure that needs only 50 votes to pass in the Senate.

But congressional rules do not allow Congress to make wholesale policy changes to Medicaid through a budget reconciliation bill -- even if members wanted to make mental health care coverage mandatory. That would require 60 votes or a larger majority in the Senate, which Republicans don't have.

"If mental health funding gets cut," Swerlick said, "it could certainly put us on a path backwards so that more people are not able to stay in their communities and end up in hospitals and institutions. The other place that people sadly end up is the criminal justice system."

Joan Alker, a researcher and Medicaid expert with Georgetown University's Center for Children and Families, said Florida would be faced with "no good choices" to fund Medicaid cost overruns under a spending cap -- a scenario she said was likely given the state's past experiences and its growing elderly population.

"The state would have to raise taxes or cut Medicaid or other areas of the state budget, like education, or all of the above to keep up with demand," she said.

Florida already has faced unexpected cost increases for Medicaid, and this year the Legislature gutted a statewide system created in 2016 to coordinate mental health care for patients.

State Sen. René Garcia, a Hialeah Republican, said that with Florida facing an opioid crisis and a sustained need for more mental health services, Medicaid caps could put added stress on county hospitals, police, courts and jails -- where many living with mental illness often end up.

"We better damned right figure out how we're going to increase or focus more attention on substance abuse and mental health," he said.

Investing more in mental health, Garcia said, would pay off.

"That means we're not using our police officers, we're not using our judges, and we sure aren't using the jails to warehouse -- and I hate to use the word warehouse but that's what's happening," he said. "If you add all those three components ... if we invest early on, that pays itself off."

For the Kalicks, Haylee's mental illness has affected more than her ability to lead a normal life. It has also kept Bruce Kalick from pursuing his profession.

A former marketing executive for a national home warranty company and for local newspapers, including the Miami Herald, Kalick now works as an independent consultant.

A single parent, Bruce Kalick said he has been unable to hold a full-time job for very long because of his daughter's needs. She would call him repeatedly whenever he was at work, he said, and she was often manic and sometimes suicidal, sending him bolting from the office to tend to his daughter.

"At any given moment, I'd have to take off and go to her and call an ambulance or police," he said. "No employer is going to put up with that."

For about five years, Bruce and Haylee Kalick lived in a Marriott Suites hotel in Weston because the rent was affordable but also because hotel staff members would check on Haylee in her room while Bruce went to work.

"The people that worked there became family to us," Haylee Kalick said.

On several occasions, Bruce Kalick said, hotel workers called an ambulance for Haylee -- twice when they found her unconscious on the floor with a spilled bottle of pills beside her and another time when a medication side effect mimicked a stroke symptom.

"They literally saved her life three times," Bruce Kalick said.

Without a steady income and employer health insurance, neither the father nor the daughter, when she became an adult, could afford her prescription drugs, which can cost up to $1,500 a month, or her counseling and psychiatric therapy, which can cost as much as $200 per session, Bruce Kalick said.

And with each psychiatric commitment came another bill of $5,000, he said.

About a year ago their finances got so tight, Bruce and Haylee Kalick moved in with Bruce's parents in Weston.

Even when Bruce Kalick had jobs with health benefits, he said, the plans often had high deductibles and co-insurance rates. And they offered little coverage for mental health and his daughter's prescription drugs.

"We had more of a problem with regular insurance than we've had with Medicaid," he said.

Haylee Kalick takes five different medications, including drugs that are labeled for high blood pressure and epilepsy -- conditions for which she had not been diagnosed. But Bruce Kalick said the drugs help manage the constant tics caused by his daughter's Tourette Syndrome, a condition for which there is no cure.

With regular counseling and psychological therapy, and by taking her medications every day, Haylee Kalick said she can now imagine a future with a family of her own and a career helping others with conditions similar to hers. And her dad can begin to see himself returning to a full-time job, and moving out of his parents' apartment.

"I can leave the house now, and do something," he said.

Kalick said his daughter still has some bad days when she talks about hurting herself or leaving the house for days. But he has not had to call police and commit his daughter to a hospital psychiatric ward since about 2015, he said.

"She can be a functioning person," Bruce Kalick said -- though he still won't allow his daughter to drive for fear that the stress will trigger her Tourette Syndrome.

Haylee Kalick now has a goal of her own: earning a high school equivalency diploma. She'll need a tutor but she's determined, she said.

"I try to focus on the fact that I'm not going crazy anymore," she said. "I can still be happy. Even if I don't get a high school diploma, I'm 21. I have the rest of my life in front of me.''

Daniel Chang: 305-376-2012, @dchangmiami

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