The New Freedom Commission on Mental Health
Twenty-five years after the Carter presidential commission, George W. Bush established the President's New Freedom Commission on Mental Health in 2002. The Commission was charged with identifying policies that would maximize use of existing resources, improve coordination of treatments and services, and promote successful community integration for children and adults with serious mental illness. Early on, Commission members identified unmet needs for employment and income support as major policy issues requiring resolution, which was reflected as a major goal—goal 2—in the Commission's final report (
2 ). Several of the report's more specific recommendations are germane to this area. The first is that "return-to-work should be consumer-driven" and the second calls for a dramatic increase in the quality and availability of evidence-based supported employment services.
The report also noted that "return to work should involve a multi-systemic approach" and that states should have "the flexibility to combine federal, state, and local resources in creative, innovative, and more efficient ways, overcoming the bureaucratic boundaries between health care, employment supports, housing and the criminal justice system." Finally, the report recommended that SSA evaluate the possibility of removing disincentives to employment in the SSI and SSDI programs.
What would a multisystemic approach to employment and income supports look like? It would encompass federal, state, and local systems responsible for employment, income support, supported employment, mental health, health care, housing, education, legal aid, criminal justice, asset accumulation, and other social services, as well as the business community and mental health advocacy communities. Elements of such a system might include
• Ongoing health care coverage for medical, mental health, and prescription drugs, regardless of the individual's labor force status
• Integrated and coordinated clinical services and vocational services shown to promote employment in this population
• Greater availability of secondary and postsecondary education to help individuals complete interrupted educational careers and obtain college degrees necessary for success in today's labor market
• Benefits planning and financial literacy education regarding the effects of earned income on SSI and SSDI cash payments, as well as development of life-long financial plans
• Asset development through matched savings accounts called Individual Development Accounts, authorized by the federal Assets for Independence Act (
130 ), allowing low-income workers to accumulate savings for postsecondary education or capitalization of small businesses, thereby building financial security and enabling career development without reduction of SSI or SSDI cash benefits (
131 )
• Housing that is safe and affordable for individuals living on SSI or SSDI and that is not threatened by income increases resulting from labor force participation
• Legal aid to deal with labor force discrimination, ensure access to state and local vocational rehabilitation services, and pursue enforcement of the Americans With Disabilities Act
• Peer support and self-help to combat mental illness stigma and provide role models for maintaining hope and optimism in the face of daunting barriers
• Involvement of employers and the business community in education, advocacy, and workforce development efforts that meet the needs of job seekers and organizations employing them.
The New Freedom Commission report also noted that the extreme fragmentation of our country's mental health system requires that it be transformed. This policy of transformation "calls for profound change; an upheaval and reorganization of what we know, what we do, and how we go about doing it" (
132 ). An extensive review of the literature on transformation noted that it is a complex, multidimensional process operating on many levels that requires visionary leadership, mobilization of scarce resources, persuasive communication, careful coordination of activities, and incorporation of ongoing feedback and readjustment of activities to reach particular goals (
133 ). To accomplish such a challenging agenda, the translation of research into practice is essential. Knowledge translation addresses the vexing problem, in the fields of both physical and behavioral health, of underutilization of evidence-based practice in designing and operating service systems (
134,
135,
136 ). Although similar to dissemination or diffusion, translation is distinguished by its emphasis on application of knowledge to systems rather than groups or organizations and by an interactive and engaged process between research and systems of care (
137,
138,
139 ).
The aforementioned trends offer the possibility that evidence-based return-to-work services can be coupled with public policy reforms and increased mental health and disability activism to promote employment and economic security for people with psychiatric disabilities. Policy reforms might include changes in Medicaid funding that make supported employment a reimbursable service integral to mental health recovery, removal of work disincentives, labor market restructuring through tax breaks and incentives for workers and employers, and enhanced access to postsecondary education and vocational training, in addition to addressing the causes and consequences of labor force discrimination. Reform also requires the stimulation and nurturance of transformational leadership at all levels of public policy formation and implementation, aimed at the translation of research into practice across entire systems.
Given the inertia and resistance to change of large state and federal bureaucracies, we might ask who will take the lead in either large-scale transformation efforts or gradual reforms? July 2005 saw the release of an action agenda created by seven cabinet-level departments of the federal government—Health and Human Services, Education, Housing and Urban Development, Justice, Labor, Veterans Affairs, and SSA. The agenda is entitled
Transforming Mental Health Care in America (
140 ). The report endorses the concept of transformation and presents 70 specific steps that will be taken by federal agencies. Many of the steps focus on enhancing employment opportunities and access to employment services. Around the same time, the Campaign for Mental Health Reform, a collaboration of 16 national mental health advocacy organizations, released its own report,
Emergency Response: A Roadmap for Federal Action on America's Mental Health Crisis, also endorsing the need for transformation and calling for the improvement of employment outcomes and elimination of disincentives for economic self-sufficiency (
141 ).
Many of the changes being discussed and debated have trade-offs that need to be considered in policy decision making. For example, instituting a $1 for $2 income disregard for SSDI beneficiaries, so that they could retain half of their employment earnings as well as disability cash benefits and entitlements, may not encourage individuals to earn more and leave the rolls but instead may make it more comfortable to remain on the rolls indefinitely (
142 ). Increasing the generosity of SSI and SSDI benefits may also result in "induced entry," which occurs when individuals enter the rolls who would not otherwise have done so (
143 ). Scholars attempting to estimate the effects of induced entry resulting from implementing a $1 for $2 disregard in the SSDI program have predicted increases in the rolls, ranging from a low of 75,000 to a high of 400,000 new beneficiaries over a ten-year period, which would cost between $410 million and $5.1 billion (
143,
144,
145 ). Others argue that such a policy change might reasonably be expected to result in budget neutrality or even savings to SSA in returned cash benefits or "induced exit" resulting from larger numbers of individuals leaving the rolls (
146 ). Still others caution against the use of work incentive programs for individuals with disabilities, noting that there is little convincing evidence of their effectiveness in studies of other populations, such as welfare recipients (
147 ).
As these issues are discussed and debated, advocacy organizations including those for people in recovery from mental illness, their families, disability advocates, and others can contribute a "value critical" policy analysis to this change process, which is based on social justice and economic fairness through the use of taxpayer dollars (
148,
149 ).
As is evident from the foregoing and also noted in the New Freedom Commission's report, researchers must assume responsibility for creating policy-relevant knowledge by carefully matching policy questions with appropriate research designs (
81,
115,
150 ). First and foremost, a better understanding of labor force participation by people with psychiatric disabilities is needed on both regional and national levels, using standard labor force indicators collected from representative samples (
111,
150 ). Second, meaningful data must be gathered and analyzed regarding access to, use of, and results of employment services across multiple state agencies by developing integrated reporting and management information systems along with classification of services and outcomes that is applicable across delivery systems (
42 ). Third, analysis of administrative data and follow-up research designs should be used to locate and interview individuals who seek but do not receive state and local employment services as well as those who are accepted as clients but who leave service systems before their rehabilitation plans are implemented (
115 ).
Fourth, qualitative, ethnographic studies of experiences with discrimination in the job-seeking process and at the workplace are needed to gain a better understanding of how inequality persists in the face of legislation designed to combat it (
123 ). Fifth, interviews with key informants within and outside large delivery systems can help us identify areas of inefficiency, inadequate resource allocation, and bureaucratic "irrationality" in organizational operation (
115 ). Sixth, we must insist on the use and linkage of electronic records in state and federal systems, in a way that maintains client privacy and confidentiality, to address questions regarding cost-effectiveness and cost-benefit ratios of clinical and vocational rehabilitation services, disability income support, and Medicaid and Medicare coverage (
99 ).