Healthcare Reform - What About Us?
By Linda Rosenberg
Submitted On November 21, 2008
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In recent times, there have been extraordinary events that put a pause on routine and threw our country into animated conversation but they have mostly been about bad news - 9/11, the invasion of Iraq and most recently the Wall Street bailout. The election was neither bad news nor a distraction like a celebrity meltdown, it actually mattered. And as a result of this incredible election season, America's children have a chance to grow up unaware that there's anything unusual about an African-American President or a woman running for the White House.
2008 Legislative Success
Now, it's over - the excitement, the soaring and in some cases snoring oration, the primaries and the debates - the Presidential campaigns are over. It was my great good fortune to attend the Democratic National Convention and to have affirmed in speeches and by actions that our community has indeed made progress. We had Senator Kennedy's bittersweet appearance and his steadfast commitment that was so critical to the passage of parity; Michelle Obama's unexpected reference to mental health when she talked about universal healthcare; Bill Clinton's description of a mom struggling with her sons' autism; the first ever "recovery room" at a convention; and a luncheon honoring the Campaign for Mental Health Reform that included A list celebrities as well as national and state political leaders all vocal in their support of accessible, affordable mental health and addiction treatments.
The rhetoric of the convention was matched by an extremely successful legislative year: the delay of damaging Medicaid rules on rehabilitative services and targeted case management and the introduction of the Medicaid Services Restoration Act; the passage of Medicare parity; veterans legislation that extends mental health and addictions services beyond the VA out to communities; improved collaboration between criminal justice and mental health; expansion of the disability definition in the ADA making it easier for people with disabilities to obtain protection against disability-based discrimination; and the passage of parity ending health insurance discrimination.
It is a hopeful time for people with disabilities. Our string of legislative and policy successes reflects tremendous progress. And substance use and mental health advocates - united by the Presidential campaign - can share a path forward into a new era.
The Economy and Service Capacity
But times are tough in communities across the country - and the world, people losing their jobs, their homes and their retirement savings. Many of us at the National Council have spent these last few months traveling from state to state and community to community. And we return from these trips filled with anxiety.
As states attempt to manage their budgets in a very fragile economy, increased demand for mental health services could be on a collision course with impending cuts to publicly funded services. Our already tattered mental health and addictions safety net is in grave danger of collapsing as unemployment rates soar, anxiety over the future grows and demand for services is at an all time high.
We urge states to resist cutting essential mental health and addictions services and we're lobbying for federal stimulus packages that include Medicaid relief and financial supports so that communities can meet treatment demand in the difficult months and perhaps years ahead. At the same time, our industry -the behavioral healthcare industry - has to be ready to work with the greatest efficiencies and be accountable for every taxpayer dollar. And the National Council's proud of the initiatives - our Access and Retention, Six Sigma and Process Benchmarking projects -that we've introduced to support member efforts to streamline access, creating more treatment capacity and more effectively engaging consumers and communities in the recovery process.
Our Role in a Progressive Era
Now the question being asked is what's our role in a new administration, in a new era? One of President elect Obama's challenges will be to harness the extraordinary idealism that he inspired in his campaign to a larger, national cause. We appear to be leaving behind the conservative agenda and entering a progressive era. A progressive era being shaped by the millenniums with their internet culture and by a new breed of the very rich that are using their wealth to support progressive causes and demanding accountability in return for philanthropy.
But even in a new era, the reality, pace or shape of healthcare reform - is uncertain. Washington is already abuzz with health care groups lobbying their points of view and potential candidates for healthcare posts in the new administration polishing their resumes. But economics, politics, and history suggest that any major overhaul of our healthcare delivery system will be a difficult process at best. Healthcare is now bigger than the "military-industrial complex" about which we were warned in 1950s, 1960s and 1970s; and there's no sector of the economy with more politically powerful special interests.
To date behavioral healthcare's progress has received little mainstream attention. And our community has a good story to tell. While healthcare costs have skyrocketed, our services, historically underfunded, have seen little increases. Richard Frank, Harvard economist and co-author of Better But Not Well, uses data from the National Co-morbidity Survey to make the case that more money is being spent on mental health but mental healthcare's share of GDP is constant and its share of health spending is declining while access, quality, and supports for people with mental illnesses have increased. We have data that tells a compelling story; and science that supports return on investment. So what about us?
It's almost a sure bet that the next administration will include treatments for mental illnesses and addictions in any expansion of health coverage. We'll be included in movement towards universal coverage, whether incrementally like the re-authorization of SCHIP or as part of more comprehensive reform like the plan offered by Ezekiel Emanuel (Dr. Emanuel, who is invited to speak at the National Council's conference in San Antonio, is the brother of Obama's new chief of staff Rahm Emanuel) in Health Care Guaranteed. But will inclusion in universal coverage strategies or general reform solve the fundamental problems we face? At best, reform will enable us to begin to solve our own problems.
Mental healthcare shares the problems of the larger healthcare system; and like health care suffers unintended policy consequences. We threw medicine out with the medical model, now we're talking as if we've just discovered that mental health is fundamental to health and the result is people with serious mental illnesses are dying far too young. We brought Medicaid into every possible service, promoted decentralization and the marketplace, and now we're faced with the same consequence - fragmentation.
Over the years, risk and responsibility have been downloaded from states to community organizations without the resources needed to keep pace with mental health, addiction and co-occurring treatment advances; without the resources to create organizational infrastructure that supports planned change; and without the resources needed to coordinate and ensure good general medical care for people with serious mental illnesses. Instead of investing in quality services, states have introduced intermediaries to manage what they still call their "system" - the result is a deskilled workforce and business as usual.
And in some cases, providers have lost the trust of their communities. As they've been increasingly relegated to and paid for only the treatment of people with the most serious mental illnesses, their communities have been left adrift. Mental health prevention and early intervention were very much part of the original concept of community based mental health care. We justified eliminating the funding for those services by labeling them as dollars wasted on the "worried well".
Serving your community means running a receptive and responsive organization: flexible hours that fit the schedules of people who work; emergency availability; and a presence in all aspects of the community where help is needed - schools, jails, senior centers, foster homes, and on and on. It also means offering one stop shopping, sending people to multiple sites of service doesn't work very well and doesn't work at all when there is little to no coordination.
Can we transform ourselves into organizations that will be propelled by a progressive agenda and supported by new coalitions? I think the question is answered by another question. Can we offer a vision of communities increasingly free from addictions and mentally fit; a vision of communities where those with histories of addiction and mental disorders are included not excluded from mainstream life; and can we be accountable for the quality of services we provide - with national standards and practices? Can we do as education has done, combine vision with accountability? If the answer is yes, then perhaps the new entrepreneurial philanthropy will be by our side and perhaps one day President-elect Obama will write about the staff in behavioral health as he writes about teachers in The Audacity of Hope, "There's no reason why an experienced, highly qualified, and effective teacher shouldn't earn $100,000 ... teachers in such critical fields as math and science - as well as those willing to teach in the toughest urban schools - should be paid even more."
An Actionable Agenda
But even as we think big thoughts about health care reform, the National Council remains practical and ready to move an actionable agenda.
We need to be accountable for continuity of care for people with serious mental illnesses and addictions. The National Council's Health care Collaborative Project successfully brings together behavioral health and primary care organizations offering a bi-directional approach for care, addressing the integration of primary care services in behavioral health settings as well as the need for behavioral health services in primary care. But far too often when the patient walks out the door, our responsibility ends - from hospital to community, from mental health to addiction treatment center to primary care, from the streets to the jails - we've created an array of disconnected even if well intentioned services. People with chronic illnesses and chronic problems need a home; and science has taught us that mental and addiction disorders are often chronic conditions. The patient-centered medical home - that provides care management; shifts the focus from episodic acute care to managing the health of those living with chronic health conditions; and emphasizes self-care that resonates with our recovery and resilience orientation - is a model we can embrace. And at the community level the idea of behavioral health care organizations providing a "health care home" for people with serious mental illnesses and addictions makes a lot of sense.
We need cost based plus financing that supports clinical excellence - skilled staff delivering nationally recognized practices within organizations that live by the rule, if you don't measure it you can't improve it. People want and deserve high quality services but services depend on the staff skill, and skilled staff must be adequately compensated. Low salaries have created-and are perpetuating-a recruitment and retention as well as a quality crisis for behavioral health care. We need organizations and staff that can provide state of the science behavioral health interventions, can treat and triage general health disorders and can lead site of service performance improvements. The public increasingly accepts that mental illnesses and addictions are treatable disorders and that recovery is possible. Now we must be sure that there are effective organizations and skilled practitioners.
We need a federal mental health funding stream dedicated to mental health and integrated treatment services for the uninsured. The uninsured have exceptionally high rates of untreated mental illnesses with co-occurring addiction disorders and there is no safety net. State general fund mental health dollars were reallocated to the Medicaid match. And now state plans to cover the uninsured are floundering. We have large numbers of individuals with treatable mental illnesses in our overburdened emergency rooms, in jails and on the streets ...and without access to the services that can engage them, treat them and return them to work. We're denying our economy productive taxpayers. We're wasting human lives.
We need a pool of funds to support investments by behavioral health care organizations in information technology. We talk about information technology and service transparency yet organizations that move forward to automate their clinical systems find little available support, funding, or technical assistance. A September 2006 National Council poll of community behavioral health care providers across the country indicated that 8 percent had implemented an EHR system with clinical components fully functioning. Technology offers critical support to the service improvement process; promotes the application of protocols and guidelines; helps maintain contact with individuals who move through complex systems; and holds the promise to reduce the enormous financial burden of paperwork and reporting duplication-all efficiencies that improve service quality. The time has come to walk the technology talk.
We must have increased emphasis on and greater funding for research-based education and prevention practices. We have prevention and education programs that work. Research-based prevention programs that reduce the risk of childhood serious emotional disturbance by treating maternal depression; and the Nurse-Partnership Program that has an array of consistent positive effects across multiple trials. We have research-based education programs that increase mental health literacy like Mental Health First Aid. The National Academies Institute of Medicine report to be issued later in 2008 is expected to underscore the importance of greater emphasis on prevention and health-promotion practices that can impede the onset or reduce the severity of mental health and substance-use disorders in children, youth and young adults. This report presents an excellent opportunity to place prevention practices on the new Administration's table.
The "Key Contact" Club
We can provide healthcare homes for people with serious mental and addictive disorders; we can ensure a skilled workforce, effective organizations and quality care; we can help those that are mentally ill and uninsured become productive members of their communities; we can employ the promise of technology; and we can bring research-based prevention and education to our communities. But we know from our '08 successes that we cannot do any of these things without the leadership of our members - members that have real impact, tackling what can appear to be intractable problems. We have a vision, we have an agenda, and we have a "key contact" strategy.
Under the direction of Chuck Ingoglia, our VP, Public Policy, our strategy is to establish and track a key contact system - a network of members, their boards, consumers and families who have good, and soon to be better, relationships with members of Congress. Key contacts must be committed to meeting with the elected officials and to keeping us updated on these contacts. Our plan is to have a key contact in every congressional district. We're taking what has been an ad hoc arrangement of our members reaching out to Congress and nurturing what we hope will be a formidable rolodex.
When change is being debated in Congress, we will be there. We'll leave behind references to a system in shambles; we'll lead with data; with our history as good managers of public dollars; and with an actionable agenda. But we need you at our side, as John F. Kennedy said so very long ago, "Political action is the highest responsibility of a citizen."
I look forward to hearing from you and to your involvement in the "key contact" club.
Linda Rosenberg leads the National Council for Community Behavioral Healthcare in treating children, adults and families with mental illnesses and addiction disorders across the country. She holds faculty appointments at several schools of social