Advocates in California are supporting a ballot initiative that would provide increased funding to counties for mental health services via a tax on income in excess of $1 million (see page 1).

Psychiatric News arranged a conversation among three APA members about issues raised by the initiative and about broader problems associated with mobilizing support for the funding of public mental health care in this political climate.

Paul Appelbaum, M.D., APA’s immediate past president, frequently has written and testified about the problems associated with the defunding of the mental health system. Selby Jacobs, M.D., chair of APA’s Committee on Public Funding for Psychiatric Services, is lead author of a recent paper, “Financing the Care of Individuals with Serious Mental Illness.” Gary Tischler, M.D., was study director of the Carter Commission on Mental Health, which made major recommendations concerning financing of the mental health system.

Following is an edited version of that conversation.

PN: What are the pros and cons of the California initiative itself?

Tischler: The goals are superb, but the means leave much to be desired. Like many single-issue strategies, a ballot initiative can foster a climate that invites diverse interest groups to compete rather than to seek common cause. It is also an approach that runs the risk of further segregating mental health from the broader field of health care. A better approach might be to build a broader coalition that would support an initiative aimed at addressing the needs of all of the state’s citizens whose severe chronic illnesses and disabilities require integrated medical, rehabilitative, and social services.

Jacobs: I share some of Gary’s concerns about how the money is being raised, but I also think the initiative can be viewed as a valid response to the situation in California. The plan for disbursing the money is reminiscent of Paul’s ideas about revitalizing the community mental health centers. I doubt that what is happening is generalizable to many other states. We are looking at budget cuts across the country. The California effort is only a small part of a larger task, which is analyzing all the various funding sources for public mental health and trying to maximize their potential and see how they can work more effectively together.

Appelbaum: None of us would maintain that government by proposition is a desirable way to allocate resources. Since the early 1990s, however, there has been a steady erosion in support for mental health services, and cuts are projected for the future. Conventional political efforts to secure more support have not been successful. Looking for another kind of corrective to the situation is not unreasonable when the political system has failed you. Integrated care delivered in local areas offers the most hope for patients with serious mental illness. In that respect, the initiative organizers have it right.

PN: How would you characterize this political climate, and what strategies might work for promoting increased funding for mental health services?

Appelbaum: Part of the current problem is an inaccurate perception by decision makers of the efficacy of psychiatric treatment. Historically, beginning with the 1840s, optimism about our capability to treat mental illness has prompted major infusions of resources. After World War II, for example, establishment of the National Institute of Mental Health was stimulated by what we learned about psychiatric treatment on the battlefield. More recently, the community mental health center movement in the early ’60s came about because we believed that people with serious mental illness could be treated effectively in community, rather than hospital, settings.

We need to become better at publicizing the results of research and more persuasive with the public about the difference treatment makes. We also need to reach consensus about a long-term vision that will lead to identification of short-term goals.

Jacobs: Funding for psychiatric services comes from multiple sources. The California initiative involves new funding services in the public sector for seriously ill patients, administered through state and county mechanisms. We also need to build resources in other funding domains such as Medicare, Medicaid, and employer-based and disability insurance. The country seems to be headed toward a critical time of change, and we need to be able to make a case for funding for mental health against many competing interests and in many different funding domains.

Tischler: One seeks the middle ground as a primary course of action only if one is interested in digging a hole. We should vocally and vigorously support strategies that address the moral issues of equity and equality in health care, not just the economic issue of parity. We should move away from strategies that treat health care as a commodity and promote those, like universal coverage, that treat it as a right. We should point out how both political parties are subtly shifting the entitlement equation from entitlements for the poor to entitlements for the wealthy.

PN: What should APA and individual psychiatrists be doing?

Appelbaum: As I mentioned earlier, we need to go through the difficult work of developing a consensus about a long-term vision. In terms of short-term actions, I think sometimes we compromise our ability to be effective advocates by our reasonableness. Lots of groups want a piece of the public pie. We might get further by being more aggressive ourselves, asserting the importance of mental health over and against other uses to which money might be put. We should set the stage for increased attention and resources directed to the needs of our patients.

Tischler: Health care costs are escalating at about 14 percent this year. The perception is that physicians, pharmaceutical firms, and the health care system are the biggest beneficiaries. What are we as psychiatrists willing to give to help address the problem? As individuals and as a guild, are we willing to give back something more than PAC contributions? For example, should we speak out against the egregious cost of certain psychotropic medications and back up the words by adopting a position against the acceptance of perks and the free flow of money between pharmaceutical companies and professional societies?

Jacobs: Advocates, to be effective, must be informed. Funding for mental health care received by seriously ill individuals is a complex and seemingly impenetrable array of sources, confusing eligibility rules, and peculiar benefit packages. APA’s Committee on Public Funding for Psychiatric Services has just completed a paper that describes various funding models, offers concrete examples of how the multiplicity of payers and variety of eligibility standards lead to fragmentation of care, and suggests ideas for future policy development and advocacy.

The paper, which was developed at the request of APA’s Assembly, is intended to provoke discussion and lead to action. ▪