The Bazelon Center for Mental Health Law

For Immediate Release
Wednesday, January 8, 2003

Contact: Christopher Burley at 202-467-5730 x 133 or leec@bazelon.org

Statement to President's New Freedom Commission on Mental Health
by
Chris Koyanagi
for
Bazelon Center for Mental Health Law
Children and Adults with Attention Deficit/Hyperactivity Disorder
Federation of Families for Children's Mental Health
International Association of Psychosocial Rehabilitation Services
National Alliance for the Mentally Ill
National Association of County Behavioral Health Directors
National Council for Community Behavioral Healthcare
National Mental Health Association
National Association of State Mental Health Program Directors

January 8, 2003

Public Sector Recommendations to the President's Commission on Mental Health The President's Commission on Mental Health Interim Report

I am here today on behalf of nine national mental health organizations that represent consumers, advocates, families, states, counties, and community providers. For many years we have worked together to address policy issues regarding the public mental health system. The expertise and experience regarding federal policy on mental health that these nine groups represent is very broad and very deep. Recently, we submitted papers containing unified recommendations from our organizations on most of the major policy issues the Commission has focused on since it convened last summer. Today, I would like to highlight some issues in those papers and the thinking behind them.

First, let me say we commend the Commission for the Interim report. It is right on target with regard to the status of public mental health systems. We particularly wish to underscore the importance of the Commission's statement that "the failure to prioritize mental health is a national tragedy." We certainly hope that through your good work mental health policy issues will soon receive far greater attention at the national, state and local levels.

However, the acknowledgment by the Commission of the gravity of the problems will not, of course, solve the problems nor make their solution a national priority. You are now moving on to the very important task of considering specific policy changes that might be included in your final report, and it is in this context that we are presenting you with our recommendations.

These recommendations will, we believe, significantly improve the federal government's programs and policies in support of strong and effective public systems that address the needs of people with mental illness. Some of the recommendations are easily implemented administratively with little or no cost; others require some investment of resources but will have significant impact. Others represent more fundamental change, would require legislative amendments or need the infusion of new resources. All of them, however, would move the various health and social service programs of the federal government towards a more coherent policy of recovery-oriented services designed to aid both children and adults to live, work, learn and participate fully in their communities, which is the President's primary objective.

The federal government can do far more to promote the development of public systems that meet the President's goals. Many of the problems in state and local systems stem from out-dated rules in various federal programs that we suggest you propose be changed.

We know state and local governments are facing enormous budget limitations at this time, and that there are competing priorities at the federal level. We also recognize that additional funding is not the solution for everything. Indeed, there is already a great deal of money in the system that can be far better used. Nonetheless, we want to emphasize to you that real systems change requires a real investment. We cannot achieve the goals the President set without both reforming public systems and increasing their resources in a strategic and targeted manner.

Our proposals also reach beyond the mental health system alone. We view all the relevant federal agencies that participate in this Commission as having a responsibility to both work more closely together and to change their own policies so as to create a more coherent direction for the federal government with respect to people who need mental health care. The federal government must break down the walls between the various silos. This concept applies also to cost. The fiscal impact of all proposals must be considered in toto. Higher expenditures in one program do not necessarily translate to higher expenditures for the federal government as a whole. For example, policies that have the effect of encouraging dependency or homelessness, may look fiscally responsible with respect to one agency but may result in long-term costs to many other systems. We must move away from silo thinking.

A theme from the Interim Report that resonates with us is the fragmentation and lack of collaboration at the federal level. Any number of federal programs now require states to develop interagency collaborations – it is time for the federal government to engage in similar processes. However, it is not enough to coordinate existing federal policy. When we urge collaboration, we are urging more than a directive for improved communication across federal agencies or the establishment of an interagency group. We need a meaningful effort, reflecting the kind of priority the Commission has found lacking, to align policies and develop congruent approaches to the needs of children and adults with mental disorders. Such an effort should be led by the Administration and should engage all pertinent federal departments and the Congress as well.

The federal government must remove existing barriers in federal programs that prevent effective local programing. Federal programs, particularly the large programs that provide on-going fiscal support either to individuals with mental disorders or to public systems, must reflect the new knowledge as described in the Surgeon General's report. They should also be crafted so as to emphasize principles in the recent IOM report, Crossing the Quality Chasm (safe, effective, consumer-focused, timely, efficient and equitable).

Many of our recommendations are not new. We have discussed, reviewed and promoted them in recent months (and in some cases years). There is not time to present or explain them all now, but let me highlight some.

First, the major funding programs (particularly Medicaid) currently fail to reimburse or actively discourage provision of evidence-based and best-practices. We recommend:

• Medicaid clarify its policy for reimbursing and Medicare pay for psychiatric rehabilitation services;
• Medicaid permit case rates and other bundled reimbursement strategies so as to allow a comprehensive system of care approach to service delivery. Separate billing of clinic, rehabilitation and the Medicaid-only service of "targeted case management" is nonsensical.

Along the same theme, the federal government has done little to provide states and localities with the wherewithal to enable children to receive services in their own homes. The result is the tragedy of custody relinquishment so well highlighted in the recent ABC News Prime Time report. Several changes to federal law and policy could improve systems of interagency care for children, such as:

• Provide states with resources -- through Medicaid, child welfare or IDEA -- to enable them to offer children services while they remain with their families.

Children are receiving more mental health services through schools than through any other public system. Yet there is no systematic Department of Education policy on school-based mental health issues. We need:

• Improved identification and early intervention mental health services through schools (in collaboration with mental health).
• Professional development and staff training to ensure improved identification and services for children with mental and behavioral disorders.
• Greater attention to positive behavior supports, as opposed to suspending or expelling children without services -- zero tolerance for mental disorders in children is absurd.
• Improved access to special education and related services and supplementary aids and services for children with behavioral health problems.

The Commission has correctly drawn attention to the tragedy of the 80% unemployment rate among adults with mental illness and the staggering cost associated with disability benefits. The President's New Freedom Initiative calls for full implementation of the 1999 Ticket to Work and Work Incentives Improvement Act. We urge the Commission to examine how this law can be more effectively targeted to people with mental illness. Federal rules, while improved in recent years, still present a barrier to employment. Critically, appropriate vocational rehabilitation services -- particularly supported employment -- must be as available to this population, as they are to others with disabilities.

Adults and children too often end up in the criminal or juvenile justice system due to failures of our mental health service systems. The answer is not improved mental health care in jails, prisons and detention centers–it is meeting these individuals needs for care long before they become offenders or delinquents. We need diversion programs of all kinds as well as re-entry initiatives.

We need federal support for evidence-based programming that focuses on this hard to serve population and we need to strengthen the social services safety net to address their housing, income and other needs.

Once in these systems, reintegration into the community is actively hampered by federal law and federal rules. Medicaid, Social Security, Food Stamps, Public Housing and TANF all need changes to enable ex-offenders to reintegrate into their communities.

Adults cannot successfully live in communities (and they are unlikely to respond to mental health treatment providers) if they are homeless, hungry or penniless. Children will fail if they do not have access to a free and appropriate education. Many specific changes are recommended in these papers to change counterproductive federal policy in this regard.

With respect to housing, HUD should continue its effort to refocus programs under the McKinney-Vento Homeless Assistance Act on ending chronic homelessness and ensuring the long term viability of permanent supportive housing serving homeless adults with mental illness.

There is a growing crisis with respect to the many adults and children with co-occurring substance abuse disorders. The federal government should allow states and localities the flexibility to furnish integrated treatment through cross-trained staff so this population can receive state-of-the-art care. It is time to stop arguing over what is best for bureaucracies and focus on what is best for consumers.

Finally, we have recommended some policy changes with respect to workforce issues. In particular, we are concerned at the potential crisis in leadership as many of those in our field are likely to retire in the near future. It is also a serious problem that professional schools frequently fail to train their students in state-of-the-art care or in skills required for effective service delivery in public systems, such as interdisciplinary team work.

These are just some of the highlights from our papers; I urge you to take a serious look at all of the policy changes we are recommending.

The challenge before this Commission and ultimately the challenge for this country is to identify and embrace concrete steps that can and should be taken to ensure that Americans with mental illnesses not fall through the cracks, that lives not be lost and that recovery is a realistic goal of services. In short, we urge this Commission to grapple with the question, how can mental health be made a national priority, and make your final report a vibrant blueprint for realizing that goal.

The Bazelon Center for Mental Health Law is the leading national legal-advocacy organization representing people with mental illness or mental retardation. Through precedent-setting litigation and in the public-policy arena, the center works to define and uphold the rights of adults and children who rely on public services and ensure them equal access to health and mental health care, education, housing and employment. The nonprofit organization is supported primarily by private foundations and individuals.