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.
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