This post is co-authored with Michael B. Friedman, LMSW.
The new President and a confident, conservative Congress will create grave threats to America’s mental health system—if they succeed in repealing the portions of the Affordable Care Act that increased access to mental health services, if they succeed in changing Medicaid from an entitlement to block grants, and if they succeed in changing Medicare to a voucher system.
Given these threats to the current, inadequate mental health system, this is clearly a time for unified action by all mental health advocates—action both to prevent erosion and to press for progress.
Why is it so important to protect current resources and to seek more?
• 20-25% of Americans have a diagnosable mental and/or substance use disorder per year. Only 40% get treatment.
• Of those who get treatment, less than 1/3 get minimally adequate treatment.
• 5-6% of American adults have a serious mental illness; about 2% have disorders that are long-term and disabling, contributing to very high rates of unemployment and poor living conditions.
• 30-40% of homeless adults and 15-20% of people in jails and prisons in the United States have a serious mental illness. This is often accompanied by substance abuse problems in both these populations.
• As many as 10% of children have a serious emotional disturbance, contributing to school failure and other serious problems.
• As the number of older adults doubles over the next two decades so will the number of older adults with mental disorders. This includes 5.2 million older adults who currently have Alzheimer’s disorder or other dementia. Without advances in prevention, this will rise to 11 million older adults with dementia by 2050.
• There will also be massive growth of minority populations, and the mental health system already has a tremendous shortage of culturally competent personnel.
• Mental and substance use disorders cost hundreds of billions of dollars per year for: (1) treatment of these conditions, (2) treatment of related health conditions which are often made more severe, more disabling, and more expensive by behavioral health disorders, (3) government funding of various social welfare benefits to support people diagnosed with mental and substance use disorders, (4) criminal justice activities, and (5) lost productivity due to inability to work.
Virtually all mental health advocates agree on the need for a better system. Now we need to rally around an agenda of urgent goals.
A 10-Point Agenda of Goals
1. Preserve Current Capacity: The Affordable Care Act has resulted in health and behavioral health insurance coverage for 20 million people who did not previously have health coverage at all and an additional 12 million people who did not have behavioral health coverage. We should demand that these people continue to be covered.
2. Increase Capacity and Improve Access: Since fewer than half of the people who could benefit from behavioral health service get it, there needs to be a multi-year commitment to increase service capacity, including rehabilitation services and a broad range of community supports—especially housing— for those with the most serious disorders as well as treatment interventions for the broader population of people with less severe disorders.
Proposals for growth must be based on realistic estimates of the scale of needed expansion. Given the fact that treatment for mental health and substance abuse services now costs over $220 billion per year, current behavioral health reform proposals barely scratch the surface of the need for expansion. Only Medicaid and Medicare are major sources of funding increases.
3. Preserve Medicaid and Medicare As Entitlements: Growth of the mental health system over several decades has come primarily from Medicaid. And over the past decade Medicare has grown as a funder of mental health services from paying 7% of all costs to 14%, an almost proportionate share. Loss of these programs as entitlements would virtually cut off increased funding for mental health and substance abuse services.
4. Remove barriers to access: In addition to increasing service capacity, efforts need to continue to remove barriers to treatment. Full implementation of parity requirements is essential as are increased efforts to overcome stigma.
5. Improve quality: Most people who get behavioral health services do not get services that are even minimally adequate. Fewer than 15% of those who are treated by primary care physicians—an increasingly common way to provide treatment for mental illness—and fewer than 50% of those who are treated by mental health professionals get minimally adequate treatment.
Improving quality of care requires major changes in both the preparation of the behavioral health workforce and in the structure of service delivery. These changes include:
• Increased biomedical, clinical, epidemiological, and services research and the translation of research findings into practice and
• Enhanced integration of physical and behavioral health services.
Overall, improving quality will require continued modifications of practice, organization, and finance models.
Critically important are complex changes in the relationship between providers of service and those who use behavioral health services to make these services “person-centered” and “recovery oriented”.
6. Reduce the suicide rate: Although today’s mental health headlines are about rare instances in which a person with a serious mental illness commits a mass murder, in truth they commit only 4-6% of homicides, (about 800 per year). They are far more likely to be victims than perpetrators. And they are far more likely to kill themselves (about 40,000 per year). The nation must redouble its efforts to prevent suicide, including restricting access to lethal means.
7. Enhance substance abuse policy: Substance abuse, including the recent rise in opioid addiction, results in high rates of avoidable deaths, serious health conditions, incarceration, and lost human potential. Prevention and treatment must be at the center of the nation’s efforts to address substance abuse problems.
8. Enhance criminal justice policy: Sadly, encounters between people with serious mental illness and the criminal justice system sometimes result in avoidable deaths. In addition, hundreds of thousands of people with serious mental illness are unnecessarily incarcerated in jails and prisons, often for minor offenses. Improved police intervention, expansion of diversion programs—such as mental health courts—and a re-working of the American bail system are needed.
9. Build a hopeful future for children and adolescents with mental health problems: In addition to increasing service capacity and improving quality of care, there must be:
· Far greater attention to the social determinants of mental and/or substance use disorders—especially poverty and violence in families and neighborhoods
· Earlier identification and intervention
· Improved collaboration among child serving systems—behavioral health, health, education, child welfare, and juvenile justice.
10. Prepare for major demographic changes: Over the coming decades there will be two major demographic shifts in the United States. Minority and immigrant populations will gradually become the majority, and people 65 or older will grow to about 20% of the population, roughly equal to the population of children under 18.
For minority populations the critical need is to build a culturally competent behavioral health system. This includes culturally sensitive practice, efforts to address lingering racism and discrimination, and inclusion of more minorities as treatment providers, managers, planners, and policy makers.
For older adults, the critical need is to build a generationally competent behavioral health system with an emphasis on helping older adults to live in the community, despite physical and mental disabilities. Particularly important are appropriate residential settings, mobile services, integration of physical and behavioral health care, improved care for people with Alzheimer’s and other dementias, and support for family members, who provide 80% of the care for older adults with disabilities.
Avoid ideological disputes that paralyze change: This 10-point agenda to protect and improve America’s mental health system is challenging and complex. Efforts that have focused on constructing comprehensive behavioral health service delivery systems and financial models to support them have been stymied not just by stubborn divisions between the political parties, but also by vituperative ideological differences within the mental health community. Effective joint action will require putting aside debates fueled by ideological differences regarding coercive interventions, return to asylums, confidentiality, priority populations, and gun control so as to focus instead on the critical issues about which virtually all advocates agree.
We must put aside our differences and work together for preservation and improvement of our nation’s mental health system. The cost of failure is far too high.
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Michael B. Friedman, LMSW is retired Director of the Center for Policy, Advocacy, and Education of the Mental Health Association of New York City and an Adjunct Associate Professor at Columbia University School of Social Work. Kimberly A. Williams, MSSW is the President of the Mental Health Association of New York City and Chair of the National Coalition on Mental Health and Aging.