MH Commission Avoids Crucial Funding Issues, Appelbaum Says

The President’s New Freedom Commission on Mental Health has “unreasonably limited” its examination of problems with the mental health system by focusing exclusively on budget-neutral solutions, APA President Paul Appelbaum, M.D., said in a recent press statement.

At a November 1 press conference, commission chair Michael F. Hogan, Ph.D., issued an interim report describing the barriers to the delivery of effective mental health care. The commission is scheduled to deliver its full report, with recommendations, to President George W. Bush by May 2003.

Appelbaum said a “broad societal response” is necessary to the “perilous state of financing for mental health.” In particular, he cited the problems of unequal access to private insurance coverage for mental health and in reimbursement for mental health treatment under Medicare.

He told Psychiatric News, “Cuts in Medicare reimbursements, the surrender of the Medicaid program to managed care companies, and reductions in state-funded programs for patients with serious mental illnesses have created a crisis situation in many states that must be addressed.”

Appelbaum called for Congress to pass and send to the president a comprehensive mental health parity bill requiring equal coverage for mental illnesses and other medical illnesses.

Hogan said at the press conference, “None of us [commissioners] was surprised by the problems. But we were surprised by their scope and complexity.”

(See Original article: article below for comments by Anil Godbole, M.D., one of the commission’s three psychiatrists.)

According to the interim report, “The commission is united in the belief that the mental health service delivery system needs dramatic reform. It is becoming clear that the mental health service system does not adequately serve millions of people who need care.”

Hogan added, “A parent seeking treatment for his child told us, ‘The system is opaque.’ ”

He noted that the last presidential commission on mental health, which was appointed by Jimmy Carter, issued its report in 1978.

Some of the measures designed to address problems outlined in that report “made things worse,” according to Hogan.

The interim report asserts, “Many of the problems are due to the ‘layering on’ of multiple, well-intentioned programs without overall direction, coordination, or consistency. The system’s failings lead to unnecessary and costly disability, homelessness, school failure, and incarceration.”

Hogan described other structural problems. “The big money for mental health services comes from the federal government, but responsibility for administration is at the state and local levels.”

Medicaid has become the primary source of public funds for mental health services, but that program was not designed to provide those services, he told the audience.

“Much that is positive has happened since the last presidential commission,” Hogan said. “Then, doctors had hunches about what might work. Since then, we’ve developed effective treatments.”

He added, however, that half of all people who need treatment do not receive it. The rate is even lower for racial and ethnic minorities, and the quality of care they receive is poorer.

Barriers to Care

The presidential commission identified five barriers that impede access to care—fragmentation and gaps in care for children, fragmentation and gaps in care for adults with serious mental illness, high unemployment and disability for people with serious mental illness, lack of care for older adults with mental illness, and failure to establish mental health and suicide prevention as national priorities.

In the interim report, the description of each barrier is followed by an account of a community-based program that successfully addresses the problems associated with the barrier.

At the press conference, Hogan focused on the prevalence and cost of high unemployment for people with serious mental illness.

People with mental illness are the largest and fastest growing group of people with disabilities receiving Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) payments. An estimated $25 billion is spent annually for those payments, but the benefits still are not adequate to secure safe housing.

In addition, SSI and SSDI benefits are linked to eligibility for health care coverage under Medicaid. Many people with a mental illness find that they cannot afford to go back to work because they would lose their Medicaid coverage.

According to the report, “Thousands of people with a mental illness make a conscious choice to stay on disability assistance because it provides Medicaid coverage for their expensive medication and treatment needs.”

APA to Offer Alternative Vision

In his press release, Appelbaum announced his appointment of a Board of Trustees task force that will develop a model of what a vital and well-functioning mental health system should look like.

APA Vice President Steven Sharfstein, M.D., the task force chair, told Psychiatric News, “We will be looking at the problems in light of psychiatric values and ethics with the aim of describing what we would want for the organization and delivery of mental health services.”

Sharfstein shares Appelbaum’s concern about the commission’s failure to acknowledge the “systematic defunding of mental health services.”

“In 1978,” he said, “at the time of the last report on mental health by a presidential commission, 8 percent to 9 percent of the health care dollar went to mental health services. Now it is between 2 percent and 3 percent.”

Go Beyond Cost Neutrality

Sharfstein thinks that commission members should make a broader interpretation of its mandate to provide cost-neutral solutions. “They should consider, for example, the costs to the criminal justice system of inadequate funding for mental health.”

He noted the blurring of lines between the public and private sectors and that cost-shifting occurs between them.

“Medicare and Medicaid are critical for financing treatment, and the commission should take a serious look at how some of their policies pose barriers to care from the private sector,” he said.

Members of the APA task force are Norman Clemens, M.D., David Fassler, M.D., Michelle Riba, M.D., Susan Padrino, M.D., and Roger Peele, M.D.

They plan to issue their report by May 2003, when the New Freedom Commission issues its final report.

On November 12, APA President-elect Marcia Goin, M.D., had an opportunity to urge the commission to broaden its scope and consider the financial and social costs of the crisis in access when she met with Hogan and three other commission members in Los Angeles.

She told Psychiatric News, “I described the problem in Los Angeles County, which has a population of 10 million and only 230 psychiatric beds for the uninsured. Emergency rooms are overwhelmed. I also was able to describe similar problems in other states because of information provided by APA’s Assembly.”

Commission members had visited the Los Angeles County Jail, which offers “an exemplary mental health treatment program.” “But,” Goin told the group, “people with serious mental illness and substance abuse disorders are filling the jail system because treatment is not available for them through the mental health system.”

She argued that dollars directed to the mental health system should, in the long run, result in savings in criminal justice cost.

Goin urged APA members to post comments about the crisis in access on the public comments page of the commission’s Web site and to send her a copy. The addresses are www.mentalhealthcommission.gov/comments.html and [email protected].

The New Freedom Commission on Mental Health was established by executive order on April 29. Bush asked the commission to recommend improvements in the U.S. mental health service system for adults with serious mental illness and for children with serious emotional disturbances.

He requested a review of both public and private sectors to identify policies that could be implemented by federal, state, and local governments to maximize the usefulness of existing resources, improve coordination of treatments and services, and promote a full life in the community for people with mental illness.

The interim report and minutes of meetings of the New Freedom Commission on Mental Health are posted on the Web at www.MentalHealthCommission.gov. ▪