APA Helps DBs Respond To Growing Medicaid Crisis

On January 13 the Kaiser Commission on Medicaid and the Uninsured released a report showing that 49 states had planned or implemented Medicaid cuts in Fiscal 2003. Thirty-two states had planned or implemented a second round of cuts (see chart).

Irvin (Sam) Muszynski, J.D., director of APA’s Division of Healthcare Systems and Financing, and his staff have been helping district branches as they attempt to fight against the cuts and deal with their consequences. APA Medical Director James H. Scully Jr., M.D., recently appointed him head of an APA team that assists district branches with immediate problems and also will develop and implement long-term strategies.

Muszynski responded to questions from Psychiatric News about Medicaid and APA’s role in addressing the crisis.

Q. What is the significance of the cuts in Medicaid budgets?

A. At the most basic level, Medicaid is the primary source of funds for public mental health services. But the recent cutbacks also have to be placed in historical context in order to understand why their impact is so devastating.

For many years, treatment, at least for those with serious mental illness, occurred primarily in institutions. With the development of new medications and psychosocial treatment techniques, treatment moved into the community, and many institutions, particularly those in the public sector, closed. As we all know, sufficient funds were never allocated for an effective, public, community–based system.

Now, however, Medicaid cuts will further jeopardize an already underfunded system. In fact, “meltdown” is the most appropriate word to describe what could happen. We are not transitioning to another kind of system. There are no institutions or resources available that could take the place of the besieged public mental health system if it collapses. (Original article: See box for comments from APA members.)

Q. What actions has APA taken to address these problems?

A. When he was APA president, Paul Appelbaum, M.D., directed the Council on Advocacy and Public Policy, chaired by Jeremy Lazarus, M.D., to make the Medicaid funding crisis a priority. APA Medical Director Jay Scully asked me to coordinate the effort across departmental lines. We have a team in place that involves staff from the Division of Government Relations and the Division of Communications and Marketing and probably will involve staff from the Office of Research.

We have already offered substantive assistance to more than 20 states that have faced budget cuts. We prepared testimony, provided on-site help with development of strategies based on local conditions, and offered various kinds of information useful in making a case for the importance of mental health services. We have been particularly involved in issues relating to access to medication.

In January we began working in a coalition with the National Mental Health Association [NMHA] and the National Alliance for the Mentally Ill [NAMI] to develop a coordinated strategy to these problems. We held a joint press conference at APA’s annual meeting to describe the problem and our future advocacy efforts. We have met or held conference calls at least weekly since January.

Q. Why has APA decided to work in a coalition?

A. We all need each other, and the alliance is very natural and potentially powerful. Families, patients, and physicians have common concerns about access to care, but we also have different perspectives and audiences whom we can reach.

Q. What kinds of activities are planned, and what help can district branches expect now?

A. I urge any district branch that needs help to contact me at [email protected] or (703) 907-8594. We will work out a plan for assistance based on the local situation.

With NAMI and the NMHA, we will be developing media and informational material that can be used to generate publicity and to persuade legislators and state officials. We will offer guidance in how the material can be adapted for each state and situation.

In our work so far, we have found that our educational efforts had to go beyond issues of stigma to helping state officials and others understand what constitutes effective treatment. As a medical specialty society, APA has a special role to play in that process.

We will also sponsor a series of forums and conferences that will begin to identify solution-based strategies and to identify gaps in our knowledge. Access to medication will always be of special importance to APA, and we will address issues relating to evidence-based prescribing. Few, if any, efforts have been made to monitor the effects of preferred drug lists on patient outcomes. We also have a special role in that activity.

Q. How might this crisis in public funding affect the private mental health sector?

A. The two sectors are inextricably intertwined in many ways. Training and supply of psychiatrists will be affected if the public sector is no longer viewed as a place where one can practice good medicine. Dedicated doctors have told me that cost restraints and requirements of Medicaid under managed care may result in their refusing to see Medicaid patients because of compromised care.

When substance abuse and mental health clinics close down, as they did in Oregon when public funds were cut [Psychiatric News, April 4], even people who can afford to pay cannot access care.

Related information will be posted on APA’s Web site at www.psych.org as it becomes available. The APA document “A Vision for the Mental Health System” is posted at www.psych.org/news_stand/visionreport040303.pdf. ▪