Chance to Make a Difference

This past spring, President Bush announced the creation of a new commission to assess the current state of mental health services in the United States and to make recommendations for improvement. The members of the somewhat grandiloquently named President’s New Freedom Commission on Mental Health were appointed over the subsequent months, and the group has now begun its work. At a time of growing threats to the integrity of mental health services, this is too important an opportunity to waste.

Michael Hogan, Ph.D., the mental health commissioner in Ohio, chairs the commission, which has a highly diverse membership. President Bush has given the group only one year of life; its report is due by next spring, after which it will go out of existence. This is an extremely aggressive timetable for a body that is being asked to address a complex area that spans the public and private sectors. Perhaps most problematic of all, the commission reportedly has been told that whatever recommendations it makes ought not to involve major new expenditures of resources.

APA was invited to testify at the commission’s first public hearing, where we were ably represented by Darrel Regier, M.D., M.P.H., director of the American Psychiatric Institute for Research and Education (APIRE) and one of the country’s leading experts on the mental health service system. He pointed to seven barriers to persons with mental disorders obtaining adequate treatment:

• Failure to recognize mental disorders

• Failure to access treatment due to stigma

• Inability to pay for available treatment

• Inadequate treatment resources in some areas

• Inadequate insurance coverage—lack of parity-level benefits

• Inadequate resources and organization of care in the public sector

• Lack of coordination of public and private sectors of care

As Dr. Regier correctly said, “Reducing the remaining barriers to care depends primarily on a new commitment of the American people and their government to enact policy changes that address the financing and organization of mental health care in both the private and public sectors.”

Why is this such a crucial time for the commission to be undertaking its work? The last decade, as we all know, has seen a growing gap between the resources available for psychiatric treatment and the needs of our patients. Public sector programs have continued closing beds and imposing new restrictions on eligibility for services. Private sector insurance programs almost universally have carved out their mental health care, turning it over to the less-than-tender ministrations of the managed care industry. Managed care’s progressive reductions in payments to practitioners and facilities have forced a steady shrinkage in the number of inpatient units and outpatient clinics, and in the availability of private practitioners who accept insurance coverage in exchange for care. Taken as a whole, these changes have led to a crisis of access in many parts of the country, the consequences of which include tens of thousands of persons with mental illness confined in jails and prisons, acutely ill patients waiting for days in emergency rooms for inpatient beds to become available, and waiting lists of weeks to months for outpatient care.

Even more frightening than merely recounting this litany of failure is the recognition that this systematic defunding of psychiatric care occurred during the most sustained and—dare I say—exuberant period of prosperity this country has known. Now, in a very different economic climate, things are going to get only worse.

The abject failure of managed care to constrain the increase in medical care costs for more than a few years means that businesses are seeing annual increases in their health insurance premiums of 10 percent to 30 percent or more in some areas. Employers are agitating for the ability to provide stripped-down benefit packages at reduced cost—with mental health coverage the first element to be stripped away. Alternatively, businesses are looking to shift more of the cost of health care to patients, by increasing the share of premiums that workers must pay and raising deductibles and copays. With mental health care more price sensitive than other forms of treatment, access to psychiatric services is likely to be affected disproportionately. Finally, we ought not to forget that some employers—especially smaller enterprises—are simply canceling all coverage for their workers, leaving them with no assistance whatsoever in meeting the costs of medical care.

If the public sector once offered a safety net for persons unable otherwise to access psychiatric care, that net itself is beginning to give way. The current economic slowdown, combined with a stock market in free fall, has led to a dramatic reduction in state revenues. Budget gaps in our larger states are projected in the several billions of dollars, as treasuries stagger under the combined impact of reductions in business income taxes and all-but-nonexistent revenues from capital gains. As cuts need to be made to balance state budgets, legislators and governors are looking to reductions in Medicaid funding—the largest or second largest budget item in most states—and to decreases in traditionally less popular departments, including mental health.

Thus, at the same time that fewer people will be able to cover the costs of psychiatric care from private insurance, it will be harder to obtain Medicaid, and fewer directly operated public services will be available. With pressure on care providers increasing as the number of uninsured patients grows, and as already inadequate Medicaid and managed care payments fail to keep up with the rate of inflation or are actually reduced, more hospitals will decide to close money-losing inpatient units, more clinics will throw in the towel, and more clinicians will opt for the private-pay market or look for other ways to make a living.

We cannot allow this to happen. A viable mental health system cannot survive if it is inadequately funded when times are good and then brutally slashed when the economy turns sour. With data indicating that fewer than half the people in this country with clinically significant psychiatric disorders receive any treatment as it is, there is no room to allow things to get worse.

Here is where the new Commission on Mental Health comes in. If it accepts its reported mandate of merely reshuffling the pieces on the mental health services chessboard, it will prove of no value whatsoever. There is no solution to the current problems that will not require more resources. The commission cannot fulfill its moral obligation to the people of this country who suffer from mental illness without saying this loud and clear. Whatever specific proposals it might make for improving mental health services, the commission must call attention to the ways in which defunding is creating a crisis in access for our patients.

Not all commissions are fated to have their reports filed and forgotten. In the late 1950s, during another Republican administration, the Joint Commission on Mental Health and Mental Illness produced a series of historic reports, culminating in Action for Mental Health in 1961. This report led to the Community Mental Health Centers Act of 1963—the first effort to develop a genuine system of mental health care in the United States. The New Freedom Commission would do well to keep this legacy in mind and rise to meet its own historic opportunity. ▪