Bush's Proposed MH Cuts no Sure Thing

President George W. Bush's proposed $3.1 trillion Fiscal 2009 budget requests millions of dollars of cuts in mental health programs, but critics of those reductions believe they are “dead on arrival” in Congress.

The president's budget would freeze most domestic spending programs but slash discretionary spending for government-funded health programs by more than $2 billion.

Mental health care advocates have expressed concern but not great fear about the cuts because Bush has suggested many of the same proposed cuts in the past, and Congress has always rejected them.

“What we're going to end up with is a giant continuing resolution that basically levels funds or provides slight increases” from the current fiscal year, predicted Lizbet Boroughs, deputy director of APA's Department of Government Relations (DGR), about the prevailing sentiment among congressional leaders.

The president's budget would maintain level funding for the National Institutes of Health (NIH), the nation's leading biomedical research center. His budget requests $29.2 billion for NIH, which is equal to the Fiscal 2008 appropriation.

Health care advocates point out that this is the sixth consecutive year that the NIH budget has failed to keep pace with biomedical inflation. In the past five years the NIH has lost approximately 11 percent in purchasing power due to inflation.

“It [effectively] means you're going to be awarding fewer grants, and the size of the grants you are awarding will be a little bit smaller,” said Boroughs, about the failure of NIH funding to keep up with inflation.

The proposed budget would, however, increase funding for the National Institute of Mental Health (NIMH) by $1.8 million to $1.407 billion, although that would not be enough to keep up with inflation. NIMH is an agency within NIH.

APA's DGR staff met with Thomas Insel, M.D., director of NIMH, on February 5 to discuss the impact of near-level overall funding on the institute, including a projected reduction in the number of new grants it could offer from 620 to 500.

APA staff pointed out that if NIMH issued fewer than 500 new grants, it would be the first time this decade the agency fell below that number.

The budget also proposes a small increase for the National Institute on Drug Abuse from $1.001 billion to $1.002 billion. The National Institute on Alcohol Abuse and Alcoholism would see its budget increase by $300,000 to $436.6 million.

SAMHSA Funding on the Block

The president's budget would cut the Substance Abuse and Mental Health Services Administration (SAMHSA) by $198 million, or 6 percent, for Fiscal 2009. Most of that cut would come from programs in the Center for Mental Health Services (CMHS). These programs, however, have congressional champions, who will push for full funding to be restored, Boroughs said.

Among the CMHS programs the Bush budget slates for elimination or reduction are the Minority Fellowship Program, which Bush's previous budget also tried to eliminate. In addition, grants to treat co-occurring mental disorders would be cut by $3.2 million; suicide-prevention grants and a suicide resource center would endure the largest cuts—$18.4 million; homelessness-prevention programs would be cut by $10.6 million; alternatives to seclusion and restraint would be reduced by $2.5 million; and child and family programs would drop by $11 million.

Other proposed budget items affecting SAMHSA include the Substance Abuse Prevention and Treatment Block Grant, which would receive a small increase from $1.75 billion to $1.779 billion. The increase is for “supplemental performance awards” for grant recipients that demonstrate superior performance.

The Center for Substance Abuse Treatment would be cut by $63 million to $337 million.

Mental health advocates were surprised that the administration proposed funding two new initiatives in mental health: one that would provide $2.2 million for mental health drug courts and another to provide $7.3 million to address mental health needs identified by state and local communities through a mental health targeted capacity-expansion program.

$200 Billion in Medicare, Medicaid Cuts

By far the largest cut proposed in Bush's budget is $183 billion in reductions to Medicare growth over five years. The proposed reduction would cut $12.2 billion, or 3 percent, of the $420 billion Medicare was projected to spend in Fiscal 2009. The Medicare spending reductions would come through reducing the maximum growth rate of the program from 7.2 percent annually to 5 percent annually.

Medicaid spending would also be in line for huge cuts, with its federal funding dropping by $18.1 billion over the next five years. However, the budget would provide a $19.7 billion increase in the State Children's Health Insurance Program over the same period.

A specific change that would greatly impact people with mental illness is a proposal to reduce the federal contribution toward the cost of targeted case management for Medicaid recipients, including those with serious mental disorders, by $1.1 billion over five years.

“Medicaid-targeted case managers serve as a vital link to medical, social, educational, housing, and other necessary services that enable beneficiaries to avoid crises that lead to costly hospitalization or incarceration,” according to a statement from the Bazelon Center for Mental Health Law.

VA Support Boosted

Programs for veterans would receive a 3.8 percent increase, to $44.8 billion, which includes $3.7 billion in emergency spending for fiscal 2008. The veterans funding includes $1.3 billion for the health care needs of an estimated 330,000 Iraq and Afghanistan war veterans. Although $3.9 billion of the nearly $45 billion in overall veterans' funds is designated for mental health care, APA plans to continue a push for greater accountability and congressional oversight of largely autonomous Veterans Integrated Service Networks (VISNs), which administer VA benefits on a regional basis.

“What we've always faced in the VA is how to spend the money wisely,” Boroughs said. “You can throw all of the money you want at a problem, but until you have identified clear solutions then you're just throwing money.”

One solution APA has urged is for the VA to increase the number of psychiatrists beyond the 350 currently employed to meet the growing need for them. Although APA is not advocating for a specific number of additional psychiatrists, the association has urged Congress to designate how many of the 4,000 new mental health positions the VA has begun to add will be psychiatrists. This step is needed to keep administrators from filling the vast majority of slots with the least trained mental health workers.

The budget designates $252 million for research programs focused on veterans returning from combat duty in Iraq and Afghanistan. This research is to include traumatic brain injury, polytrauma, spinal-cord injury, prosthetics, burn injury, pain, and postdeployment mental health.

The outlook for the president's budget is not bright, Boroughs said, because its deep proposed cuts for many nonmilitary domestic programs are unpopular in Congress. The administration claimed the budget will allow the government to run a surplus of $48 billion by fiscal 2012.

Bush's proposed Fiscal 2009 budget is posted at<www.whitehouse.gov/omb/budget/>.▪